Every finding on record at Majestic Care of Bedford

Based on interview and record review, the facility failed to ensure residents were provided the informed consent prior to an increase or a start of a psychotropic medications for 2 of 5 residents reviewed for unnecessary medications. (Resident 13 and 23)Findings include: 1. On 5/13/26 at 11:55 a.m., Resident 13's clinical record was reviewed. The diagnoses included, but were not limited to, dementia with psychotic behaviors and anxiety. The care plan, dated 10/30/25, indicated Resident 13 received psychotropic medication. The intervention was to educate the resident's family about the risks, the benefits and the potential adverse side effects of the prescribed medication, and to obtain the consent as indicated. The Physician Order indicated Rexulti (antipsychotic) 1 milligram (mg) was initiated one time a day for dementia with agitation, on 12/11/25. The December 2025 Medication Administration Record (MAR) indicated Rexulti 1 mg administration was started on 12/12/25. The Psychoactive Medication Consent and Management Agreement, dated 12/14/25, lacked documentation from resident's representative giving consent for the initiation of the new psychotropic medication. 2. On 5/13/26 at 11:50 a.m., Resident 23's clinical record was reviewed. The diagnoses included, but were not limited to, Alzheimer's Disease, major depressive disorder, psychotic disorder, and anxiety. The care plan, dated 4/3/26, indicated Resident 23 received psychotropic medication. The intervention was to educate the resident's family about the risks, the benefits and the potential adverse side effects of the prescribed medication, and to obtain the consent as indicated. The Physician Order indicated Vraylar (antipsychotic) was increased from 1.5 mg to 3 mg one time a day for aggression, on 4/25/26. The April 2026 MAR indicated Vraylar 3 mg started administration on 4/26/26. The Psychoactive Medication Consent and Management Agreement, dated 4/28/26, indicated Resident 23's representative gave telephone consent to increase Vraylar on 4/28/26. During an interview on 5/13/26 1:03 p.m., the Director of Nurses (DON) indicated Psychoactive Medication Consent and Management Agreement would be completed prior to an initiation or increase of a new psychotropic medication. During an interview on 5/13/26 at 1:23 p.m., the DON indicated Resident 13's clinical record lacked documentation of informed consent prior to the start of the Rexulti. Resident 23's clinical record lacked documentation of informed consent prior to the increase of the Vraylar. On 3/14/25 at 1:25 p.m., the DON provided the facility policy, Psychotropic Medication Use, dated 8/1/25 and indicated it was the policy currently being used by the facility. A review of the policy indicated, .E. Informed consent must be obtained and documented prior to initiation or an increase in dosage of a psychotropic medication, including a discussion of risks, benefits, and alternatives . 410 IAC (Indiana Administrative Code) 16.2-3.1- 3(n)(2)

Based on record review and interview, the facility failed to ensure the Discharge MDS (Minimum Data Set) assessment was completed within allotted timeframe for 1 of 1 residents reviewed for resident assessment. (Resident 108)Finding includes:On 5/12/26 at 10:18 a.m., Resident 108's clinical record was reviewed. The diagnoses included, but were not limited to, alcohol abuse, anxiety and major depressive disorder. A progress note, dated 12/18/25 at 12:50 a.m., indicated Resident 108 was transferred to the emergency room. A progress note, dated 12/18/25 at 11:38 a.m., indicated the resident would be transferred to another Long Term Care facility upon discharge from the hospital.A review of Resident 108's MDS assessments indicated there was no Discharge MDS assessment completed.A review of the Resident Assessment Instrument (RAI), 3.0 User's Manual, Version 1.20.1, October 2025, on 5/12/26 11:00 a.m., indicated the Discharge MDS assessment must be completed within 14 calendar days after the discharge date and must be submitted within 14 days after the MDS completion date.During an interview with the MDS coordinator on 5/13/26 at 12:15 p.m., she indicated the discharge MDS was not completed on discharge of the resident and should have been completed within 14 calendar days of the discharge date . She indicated the facility did not have a resident assessment policy and they use the RAI tool criteria for timeframe of completion.

Based on interview and record review, the facility failed to ensure a Minimum Data Set (MDS) assessment accurately reflected a resident's status for 1 of 32 residents reviewed for MDS accuracy. (Resident 23)Findings include:On 5/13/26 at 11:50 a.m., Resident 23's clinical record was reviewed. The diagnoses included, but were not limited to Alzheimer's disease and major depressive disorder. A review of the resident's April 2026, MAR (Medication Administration Record) indicated on 4/2/26, the resident was prescribed mirtazapine (an antidepressant medication) at bedtime for insomnia. A 4/9/26 admission MDS assessment failed to document an antidepressant prescription for the resident.During an interview on 5/13/26 at 12:08 p.m., the MDS coordinator indicated the 4/9/26 MDS assessment was incorrect and should have included the antidepressant medication.410 IAC (Indiana Administrative Code) 16.2-3.1-31(d)

Based on observation, interview, and record review, the facility failed to ensure a physician's order was current for a resident receiving oxygen via a nasal cannula for 1 of 2 residents reviewed for respiratory care. (Resident 3)On the following dates and times, Resident 3 was observed in her room receiving oxygen from a humidifying oxygen delivery machine via a nasal cannula: 5/8/26 at 1:54 p.m.5/12/26 at 10:10 a.m. and 12:13 p.m.5/13/26 at 10:35 a.m. During an interview on 5/8/26 at 1:55 p.m., Resident 3 indicated after her last hospitalization she was told to use the oxygen for another 30 days. It was past 30 days, and she was still wearing the nasal cannula and receiving oxygen, because staff told her she needed it. The nasal cannula bothered her, and she did not want to wear it if it was not necessary. On 5/11/26 at 11:05 a.m., Resident 3's clinical record was reviewed. The diagnoses included, but were not limited to, atrial fibrillation and anxiety. A review of current physician's orders indicated no oxygen was prescribed. The last physician's order for oxygen had a start date of 2/2/26 and a discontinued date of 2/23/26. During an interview on 5/13/26 at 11:35 a.m., the Director of Nursing Services indicated there was no current physician's order for oxygen for the resident. 410 IAC (Indiana Administrative Code) 16.2-3.1- 47(a)(6)

Based on interview and record review, the facility failed to protect a resident's right to be free from mental abuse by staff for 1 of 3 residents reviewed for abuse. CNA's covered a resident's face with a pillowcase during care. This deficient practice would result in a reasonable person experiencing distress, disorientation, fear, and mental anguish. (Resident B, CNA 2, CNA 3) Finding includes:During an interview on 3/10/26 at 8:21 a.m., CNA 1 indicated staff should not have placed a pillowcase over Resident B's face. CNA 1 would have stopped the staff, removed the pillowcase from Resident B's face and made sure Resident B was okay, removed the staff from resident care areas, and reported what he saw to the Administrator as abuse. The clinical record for Resident B was reviewed on 3/10/26 at 8:50 a.m. The diagnoses included, but were not limited to, cerebral palsy, severe intellectual disability, and muscular dystrophy. During an interview on 3/10/26 at 9:53 a.m., the Social Service Director (SSD) indicated she walked into Resident B's room and saw CNA 2 and CNA 3 getting ready to transfer Resident B from his bed to his wheelchair. Resident B's head was not in the pillowcase, but Resident B's entire face was covered with a pillowcase. The SSD told CNA 2 and CNA 3 to stop what they were doing and remove the pillowcase from Resident B's face. CNA 2 removed the pillowcase and they finished the transfer. The SSD immediately reported what she saw to the Administrator and walked CNA 2 and CNA 3 to the office. CNA 2 indicated to the SSD that Resident B had spit at the staff and she didn't want to be spit on.An Investigation Statement, dated 2/11/26, indicated the SSD heard Resident B yelling so she went to check on him. The SSD saw a pillowcase cover Resident B's face. The pillowcase was removed from Resident B's face and the Administrator was notified immediately. The statement was initialed by the SSD.An Investigation Statement, dated 2/11/26, indicated CNA 4 witnessed a pillowcase over Resident B's face. An addendum to this statement, dated 2/16/26, indicated CNA 4 demonstrated to the Administrator how the pillowcase was placed on Resident B's face. CNA 4 draped a pillowcase from the top of her forehead to below the chin. On 3/10/26 at 9:10 a.m., the Administrator provided a copy of a facility policy, titled Abuse, Mistreatment, Neglect, Exploitation, and Misappropriation, dated 6/2025, and indicated this was the current policy used by the facility. A review of the policy indicated residents have the right to be free from abuse.This deficient practice was corrected on 2/13/26 after the facility implemented a systemic plan of correction that included the following actions: all staff was educated on the abuse policy, with ongoing monitoring and audits.This citation relates to Intake 2741973.410 IAC (Indiana Administrative Code) 16.2- 3.1-27(a)(1)

Based in interview and record review, the facility failed to ensure staff possessed the skill sets to provide care to a resident with behavior health needs for 1 of 3 residents reviewed for behavioral health. (Resident B) Findings include:The clinical record for Resident B was reviewed on 3/10/26 at 8:50 a.m. The diagnoses included, but were not limited to, cerebral palsy, severe intellectual disability, and muscular dystrophy. A care plan, dated 11/4/25, indicated Resident B exhibited behavioral symptoms of hitting, kicking, and spitting at staff when providing care. The interventions included, but were not limited to, if Resident B becomes resistive to care or combative then postpone care and re-approach, initiated 11/4/24.During an interview on 3/10/26 at 9:53 a.m., the Social Service Director (SSD) indicated she walked into Resident B's room and saw CNA 2 and CNA 3 getting ready to transfer Resident B from his bed to his wheelchair. Resident B's head was not in the pillowcase, but Resident B's entire face was covered with a pillowcase. The SSD told CNA 2 and CNA 3 to stop what they were doing and remove the pillowcase from Resident B's face. CNA 2 removed the pillowcase and they finished the transfer. The SSD immediately reported what she saw to the Administrator and walked CNA 2 and CNA 3 to the office. CNA 2 indicated to the SSD that Resident B had spit at the staff and she didn't want to be spit on.During an interview on 3/10/26 at 12:12 p.m., the Director of Nursing (DON) indicated CNA 2 and CNA 3 had access to Resident B's cardex with the interventions that staff used to care for him. CNA 2 and CNA 3 should have known what interventions they could have used instead of covering Resident B's face with a pillowcase.On 3/10/26 at 11:50 a.m., the Administrator provided a copy of a facility policy, titled Behavior Management, dated 1/2/24, and indicated this was the current policy used by the facility. A review of the policy indicated it is the policy of the facility to provide all residents with a supportive environment aimed at relief of and/or accommodation of their behavioral needs in addition to person-centered interventions. This deficient practice was corrected on 2/13/26 after the facility implemented a systemic plan of correction that included the following actions: all staff were educated on behaviors, with ongoing monitoring and audits.This citation relates to Intake 2741973.

Based on observation, interview, and record review, the facility failed to ensure a resident received urinary incontinence care for a resident that was incontinent of urine for 1 of 3 residents reviewed for urinary incontinence. (Resident F) Findings include: On 6/25/25 from 10:59 a.m. until 11:07 a.m., observed Resident F sitting in the common area lying back in his wheelchair. There was a stream of urine running down from the wheelchair seat onto the floor where there was a large puddle of urine. Qualified Medication Aide (QMA) 1 walked up to Resident F's wheelchair and pushed it forward so the housekeeper could mop the floor. Once the housekeeper was finished mopping the area, he moved Resident F's wheelchair back. At that time, QMA 1 indicated she hadn't addressed Resident F's incontinence because the CNA's were busy and Resident F required a mechanical lift. LPN 1 was standing next to QMA 1 and QMA 1 indicated nurses were allowed to help provide incontinence care. The clinical record for Resident F was reviewed on 6/25/25 at 1:35 p.m. The diagnoses included, but were not limited to, neurogenic bladder, aphasia, cerebral palsy, seizure disorder, and anxiety disorder. A quarterly Minimum Data Set (MDS) assessment, dated 4/20/25, indicated Resident F was severely cognitively impaired, was impaired on both sides of upper and lower extremities, was dependent for activities of daily living, and was always incontinent of bladder. On 6/26/25 at 12:30 p.m., the facility was unable to provide a policy regarding incontinence care. 3.1-41(a)(2)

Based on interview and record review, the facility failed to protect the residents' right to be free from physical abuse when a severely cognitively impaired male resident grabbed another female resident by the hair, grabbed female resident's face causing a scratch, and slapped resident in the face and pushed on their eyes causing a corneal abrasion for 3 of 3 residents reviewed for abuse. (Resident B, Resident D, Resident E, Resident F) Findings include: The clinical record for Resident B was reviewed on 6/25/25 at 8:42 a.m. The diagnoses included, but were not limited to, chorea (a neurological disorder that causes involuntary, random, and continuous muscle movements while awake), cerebral palsy, anxiety disorder, and autistic disorder. A quarterly Minimum Data Set (MDS) assessment, dated 4/22/25, indicated Resident B was severely cognitively impaired and displayed verbal and physical behavioral symptoms directed towards others. A progress note, dated 6/8/25 at 2:11 p.m., indicated Resident B walked over toward the nurse's desk and as he walked by Resident D, Resident B reached over and grabbed Resident D's hair with both hands and would not let go. It took two staff members to redirect him. A progress note, dated 6/10/25 at 10:39 a.m., indicated Resident B was walking across the dining room with the CNA that was assigned to provide one-on-one supervision for Resident B that shift. As Resident B passed by Resident D, Resident B reached out and grabbed Resident D's arm with his left hand and then reached out with his right hand and grabbed Resident D's hair. Resident B would not let go of Resident D's hair. It took four people to separate and redirect Resident B. A progress note, dated 6/19/25 at 7:50 p.m., indicated Resident B reached out to adjust Resident E's face. In doing so, a scratch was made under Resident E's eye. A progress note, dated 6/20/25 at 4:35 p.m., indicated Resident B went into Resident F's room and poked Resident F in the eye leaving a scratch. When CNA 2 attempted to redirect Resident B, he began open handed slapping Resident F in the face. Resident F had swelling and redness to the left eye and bleeding in his mouth. 1. During an interview on 6/25/25 at 10:47 a.m., Licensed Practical Nurse (LPN) 1 indicated there were two times when Resident B grabbed Resident D by the hair and wouldn't let go. One time Resident D was sitting in her wheelchair and Resident B walked over and grabbed her hair. It took a few staff to separate Resident B from Resident D's hair. Each time this happened Resident D had cried and the first time she complained of pain. The clinical record for Resident D was reviewed on 6/25/25 at 1:02 p.m. The diagnoses included, but were not limited to, spastic quadriplegic cerebral palsy and autistic disorder. An annual Minimum Data Set (MDS) assessment, dated 5/8/25, indicated Resident D was severely cognitively impaired. A progress note, dated 6/8/25 at 2:34 p.m., indicated Resident B walked over toward the nurse's desk and as he walked by Resident D, Resident B reached over and grabbed Resident D's hair with both hands and would not let go. It took two staff members to redirect him. A pain score evaluation, dated 6/8/25 at 2:35 p.m., indicated Resident D had a scratch on the back of her neck and had pain. A progress note, dated 6/10/25 at 11:15 a.m., indicated Resident B was walking across the dining room with the CNA that is assigned to provide one-on-one supervision for Resident B that shift. As Resident B passed by Resident D, he reached out and grabbed Resident D's arm with his left hand and then reached out with his right hand and grabbed Resident D's hair. Resident B would not let go of Resident D's hair. It took four people to redirect Resident B. 2. The clinical record for Resident E was reviewed on 6/25/25 at 1:40 p.m. The diagnoses included, but were not limited to, muscular dystrophy, scoliosis, and myopia. A focused charting evaluation, dated 6/19/25 at 7:33 p.m., indicated Resident B had been physically aggressive toward Resident E. Resident E was seated in the main dining room and Resident B walked up and placed his hand on Resident E's face in what appeared to be an attempt to adjust Resident E's glasses. A skin evaluation, dated 6/19/25 at 7:34 p.m., indicated Resident E had a scratch below her right eye. During an interview on 6/26/25 at 9:58 a.m., CNA 1 indicated last week she was providing one-on-one supervision for Resident B. CNA 1 and Resident B were walking to the dining room and Resident E was sitting in her Broda chair. All of the sudden, Resident B reached over, opened his hand, and grabbed Resident E's face. It looked like Resident B was trying to grab Resident E's eyeballs but Resident E was wearing glasses. Resident E had a scratch and marks under where her glasses sat on her face. CNA 1 had witnessed Resident B be aggressive with multiple other residents. He likes eyeballs and sticking his fingers in other people's mouths. 3. During an interview on 6/25/25 at 10:35 a.m., CNA 2 indicated on 6/20/25 she was providing one-on-one supervision for Resident B when Resident B walked into Resident F's room. Resident B put one of his thumbs into each of Resident F's eyes and pressed on Resident F's eyes. CNA 2 yelled for help and after approximately one to two minutes the staff were able to separate Resident B from Resident F and get Resident B out of the room. Resident F was sent to the hospital. During an interview on 6/25/25 at 10:47 a.m., LPN 1 indicated, on 6/20/25, she heard someone yell for help so she went to Resident F's room. Resident F's left eye had swelled and she could see a scratch under the left eye. Resident F was sent to the hospital and diagnosed with a corneal abrasion and had antibiotic eye drops. The clinical record for Resident F was reviewed on 6/25/25 at 1:35 p.m. The diagnoses included, but were not limited to, neurogenic bladder, aphasia, cerebral palsy, seizure disorder, and anxiety disorder. A quarterly Minimum Data Set (MDS) assessment, 4/20/25, indicated Resident F was severely cognitively impaired, both upper and lower extremities were severely impaired, and was dependent for all activities of daily living. A progress note, dated 6/20/25 at 5:30 p.m., indicated Resident B went into Resident F's room and poked Resident F in the eye leaving a scratch. When CNA 2 attempted to redirect Resident B, he began open handed slapping Resident F in the face hitting Resident F in the eye and mouth causing swelling and redness to the left eye and causing bleeding in his mouth. A pain score evaluation, dated 6/20/25 at 5:33 p.m., indicated Resident F's left eye was red, swollen, and bruised with a scratch under the left eye. Resident F had pain. A progress note, dated 6/21/25 at 12:40 a.m., indicated Resident F returned from the emergency department with a new physicians order to instill one application of erythromycin ointment to left eye four times daily for a corneal abrasion. A current physicians order started, on 6/21/25 at 6:00 a.m., indicated erythromycin ophthalmic ointment 5 milligrams per gram, instill one application in left eye four times daily for corneal abrasion. On 6/25/25 at 9:00 a.m., the Administrator provided a copy of a facility policy, titled Abuse, Mistreatment, Neglect, Exploitation and Misappropriation, dated 6/5/25, and indicated this was the current policy used by the facility. A review of the policy indicated residents have the right to be free from abuse. This citation relates to Complaint IN00460596. 3.1-27(a)(1)

Based on observation, interview, and record review, the facility failed to ensure food was stored in a sanitary manner for 1 of 2 kitchen observations. Food was not discarded by the discard date and food was stored under the condenser fan. This had the potential to affect 85 of 102 residents who were served food from the kitchen. Findings include: On 3/28/25 at 10:30 a.m., during a follow-up tour of the kitchen with the Dietary Manager (DM), the following was observed: - The walk in refrigerator had a container of liquid salad dressing with an open date of 1/12/25 and a discard date of 2/12/25. - The walk in freezer had an open box of cheddar biscuits directly under the condenser fan, there was ice accumulation noted on the fan directly above the box of food. The biscuits were covered in a plastic bag inside of opened box. During an interview with the DM on 3/28/25 at 10:30 a.m., she indicated that all containers opened were good for 30 days, after 30 days they were to be discarded. The DM indicated that the container of salad dressing should have been discarded on 2/12/25. The DM indicated that food should not be stored directly under the condenser fan to allow for proper circulation and to protect food from contamination if the fan would leak. On 3/28/25 at 3:10 p.m., the Corporate Nurse Consultant provided the facility's policy, Safe Food Handling, dated 3/1/25, and indicated it was the policy currently being used by the facility. A review of the policy indicated .a. Food items are placed into appropriate storage locations consistent with Food Code Guidelines and protected from contamination. b. Leftover foods will be protected, labeled and dated with date of original preparation and date of discard . 3.1-21(i)(2) 3.1-21(i)(3)

Based on interview and record review, the facility failed to ensure the notification of the bed-hold policy required for a resident who transferred to the hospital was provided in writing to the resident or the resident representative for 1 of 3 residents reviewed for hospitalization. (Resident 41) Findings include: Resident 41's clinical record was reviewed on 3/27/25 at 2:54 p.m. The diagnoses included, but were not limited to, dementia and repeated falls. Resident 41's progress notes indicated the resident was sent to the hospital on 2/19/25. The clinical record lacked documentation of written notification which specified the facility's bed-hold policy was provided to the resident or the resident representative. During an interview at 3/28/25 at 12:27 p.m., the Director of Nursing indicated the facility did not have documentation which indicated the bed-hold policy was provided in writing to Resident 41 or to the resident representative. On 3/28/25 at 3:29 p.m., the Director of Nursing provided the facility's policy,Bed Hold dated, 12/12/23, and indicated it was the policy currently being used by the facility. A review of the policy indicated, . At the time of transfer for hospitalization or therapeutic leave, the facility will provide to the resident and/or the resident representative written notice which specifies the duration of the bed-hold policy and addresses information explaining the return of the resident to the next available bed . 3.1-12(a)(25) 3.1-12(a)(26)

Based on interview and record review, the facility failed to document and implement new interventions to prevent falls for 1 of 5 residents reviewed for accidents. (Resident 31) Findings include: On 3/27/25 at 11:20 a.m., Resident 31's clinical record was reviewed. The diagnoses included, but were not limited to, dementia, rheumatoid arthritis, and peripheral neuropathy (weakness, numbness, and pain from nerve damage). The Quarterly MDS (Minimum Data Set) assessment, dated 2/24/25, indicated Resident 31 had severe cognitive impairment and had no falls since the prior assessment. The Care Plans included, but were not limited to: - At Risk for Falls, initiated on 10/30/24. The interventions included but were not limited to: Dycem between cushion and chair, dated 2/26/25. Encourage to go to dining room for meals, dated 2/10/25. Bed against the wall, dated 1/31/25. Mat between bed and wall, dated 1/31/25. Touch pad call light, dated 1/31/25. Encourage resident to sleep in bed at night, dated 12/26/24. If resident prefers to sleep in recliner staff will assist with raising foot of chair, dated 12/26/24. Non-skid strips to be placed in front of recliner, dated 12/13/24. Therapy to evaluate and treat as appropriate, dated 12/12/24. Encourage and assist to wear non-skid footwear, dated 10/30/24. Encourage to participate in activities that promote exercise and physical activity, dated 10/30/24. Follow facility fall protocol, dated 10/30/24. Keep call light and frequently used personal items within reach, dated 10/30/24. Therapy to screen quarterly and as needed, notify therapy of changes in gait or balance, dated 10/30/24. - Resident exhibits behavior symptoms of not asking for help when needing assistance, initiated on 3/24/25. The interventions included, but were not limited to: Assess residents needs, dated 3/24/25. Maintain a safe environment, dated 3/24/25. Provide positive feedback for good behaviors, dated 3/24/25. The nursing progress notes indicated the following: - On 3/16/25 at 8:33 p.m., Resident continues on neurological checks post fall this morning. Neurological checks within normal limits. Denies pain or discomfort. Has been in room all day. No distress noted. - On 3/17/25 at 10:42 a.m., resident continues with neurological checks due to fall on 3/16/25, vital signs within normal limits, no signs, symptoms, or complaints of pain at this time. - On 3/18/25 at 6:39 p.m., resident continues with neurological checks due to fall on 3/16/25, vital signs within normal limits, no signs, symptoms, or complaints of pain at this time. - On 3/19/25 at 6:26 p.m., resident continues on neurological checks this shift. Neurological checks within normal limits. Resident denies pain or discomfort. Walked to dining room for lunch and dinner. No distress. The clinical record for Resident 31 lacked documentation and new interventions for the fall on 3/16/25 until 3/24/25. During an interview with the DON on 3/27/25 at 2:15 p.m., she indicated that the fall was not documented in record and was not reported to her at that time. The DON indicated there was no IDT (interdisciplinary team) meeting completed until today, 3/27/25. During an interview with Resident 31's daughter on 3/27/25 at 3:00 p.m., she indicated she was notified on 3/16/25 of resident's fall. On 3/28/25 at 3:20 p.m., the DON provided the facility policy, Fall Prevention, dated 1/2/24, and indicated it was the policy currently being used by the facility. A review of the policy indicated, .When any resident experiences a fall, the facility will: a. Assess the resident b. Complete a post-fall assessment c. Complete an incident report . d. Notify the physician and family. e. Review the resident's care plan and update as indicated. f. Document all assessments and actions . 3.1-45(a)(1)

Based on interview and record review, the facility failed to ensure the written notification required for a transfer and discharge was provided to the resident and the resident representative for 2 of 3 residents reviewed for hospitalization. (Resident 41, Resident 74) Findings include: 1. Resident 74's clinical record was reviewed on 3/27/25 at 10:27 a.m. The diagnoses included, but were not limited to, chronic obstructive pulmonary disease and dementia. Resident 74's progress notes indicated the resident was sent to the hospital on [DATE]. The clinical record lacked documentation of written notification of the transfer and discharge forms having been provided to the resident representative. During an interview on 3/27/25 at 11:30 a.m., the Administrator indicated the facility did not have documentation which indicated the transfer and discharge forms were provided in writing to Resident 74's representative. 2. Resident 41's clinical record was reviewed on 3/27/25 at 2:54 p.m. The diagnoses included, but were not limited to, dementia and repeated falls. Resident 41's progress notes indicated the resident was sent to the hospital on 2/19/25. The clinical record lacked documentation of written notification of the transfer and discharge forms having been provided to the resident and to the resident representative. During an interview at 3/28/25 at 12:27 p.m., the Director of Nursing indicated the facility did not have documentation which indicated the transfer and discharge forms were provided in writing to Resident 41 and to the resident representative. On 3/28/25 at 3:29 p.m., the Director of Nursing provided the facility's policy,Transfer and Discharge dated, 12/12/23, and indicated it was the policy currently being used by the facility. A review of the policy indicated, . 4. the facility's transfer/discharge notice will be provided to the resident and the resident's representative in a language and manner in which they can understand . 3.1-12(a)(6)(A)(i) 3.1-12(a)(6)(A)(iii)

Based on observation, interview, and record review, the facility failed to provide treatment or services to prevent further decrease in range of motion for 3 of 5 residents reviewed for mobility. (Resident 29, Resident 63, Resident 79). Findings include: 1. During an interview on 6/10/24 at 11:07 a.m., Resident 29 indicated she had a stroke and her left side was affected. She had therapy for her left arm and hand contracture (permanent tightening of the muscle, tendon, skin, and nearby tissues that caused the joints to shorten and become stiff). When she was finished with therapy, they did not have a nursing restorative program to assist with her range of motion exercises. At that time, Resident 29 was observed to have a left hand contracture. On 6/12/24 at 2:57 p.m., Resident 29 was observed to be in her wheelchair. Her left hand and wrist were contracted and was resting on her lap. On 6/12/24 at 10:37 a.m., Resident 29's clinical record was reviewed. The diagnoses included, but were not limited to, cerebrovascular disease (stroke) affecting left side, hemiparesis (weakness on entire side of the body), muscle spasm, wrist contracture, and muscle weakness. The Discharge Notification from Therapy, dated 2/6/24, indicated the discharge recommendations were to continue with upper extremity home exercise program. The Occupational Therapy Discharge Summary, dated 2/16/24 at 12:06 p.m., indicated discharge recommendations of restorative range of motion program to her upper body. The Functional Abilities and Goals Assessment, dated 5/20/24 at 10:06 a.m., indicated Resident 29 had functional limitation of range of motion on one side of her upper and lower extremities. The Quarterly Minimum Data Set (MDS) assessment, dated 5/20/24, indicated Resident 29 was cognitively intact, had limited range of motion on one side of her upper and lower extremities, and was not on a active or passive range of motion restorative program. The care plan, dated 6/11/24 and current through target date of 9/11/24, indicated Resident 29 needed assistance with activities of daily living related to cerebrovascular disease with left sided hemiparesis. The care plan lacked documentation of active or passive range of motion or any services to prevent further decrease in range of motion. During an interview on 6/12/24 at 10:02 a.m., Certified Occupational Therapist Assistant (COTA) 1 indicated Resident 29 had a stroke and had functional limitation of her left upper extremity. When she was discharged from the occupational therapy, she would of benefited from a range of motion restorative program. The facility lacked a range of motion restorative program. During an interview on 6/12/24 at 3:03 p.m., CNA 1 indicated Resident 29 had left-sided weakness and left hand contracture. Resident 29 did not have any active or passive range of motion restorative program. During an interview on 6/13/24 at 12:05 p.m., the Director of Health Services (DHS) indicated Resident 29 did not have a nursing restorative program or any services to prevent further decrease in range of motion of her left upper and lower extremity. 2. During an interview on 6/10/24 at 10:15 a.m., Resident 63's wife indicated he had a fall and had a traumatic brain injury. He was quadriplegic and had limited movement to his arms and legs. When Resident 63's therapy was finished, they did not recommend a range of motion restorative program because the facility did not have a restorative program. On 6/12/24 at 10:01 a.m., Resident 63 was observed to be sitting in his wheelchair in the day room with his wife. She was observed to raising his right arm and saying [Resident name] let's do your exercises. On 6/13/24 at 10:02 a.m., Resident 63 was observed to be sitting in the day room with his arms crossed on his chest. On 6/12/24 at 12:49 p.m., Resident 63's clinical record was reviewed. The diagnoses included, but were not limited to, traumatic brain injury and quadriplegia. The care plan, dated 6/29/23 and current through target date of 8/30/24, indicated Resident 63 needed assistance with activities of daily living. The care plan lacked documentation of active or passive range of motion or any services to prevent further decrease in range of motion. The Occupational Therapy Discharge Summary, dated 3/7/24 at 12:04 p.m., indicated recommendations of assistive device for safe functional mobility. The Functional Abilities and Goals Assessment, dated 4/20/24 at 1:38 p.m., indicated Resident 63 had functional limitation of range of motion on both sides of his upper and lower extremities. The Quarterly MDS assessment, dated 4/20/24, indicated Resident 63 had severe impaired decision making ability, had limited range of motion on both sides of his upper and lower extremities, and was not on a active or passive range of motion restorative program. During an interview on 6/12/24 at 3:03 p.m., CNA 1 indicated Resident 63 had limited range of motion to both upper and lower extremities. Resident 63 was not on a range of motion restorative program. During an interview on 6/13/24 at 10:50 a.m., COTA 1 indicated when Resident 63 was discharged from occupational therapy on 3/7/24, range of motion restorative program was not recommended because the facility did not have a restorative program. Resident 63 would benefit from a passive range of motion restorative program. During an interview on 6/13/24 at 12:05 p.m., the DHS indicated Resident 63 did not have a nursing restorative program or any services to prevent further decrease in range of motion of both of his upper and lower extremities. 3. During an interview on 6/10/24 at 2:24 p.m., Resident 79 indicated she had broken her leg. She had therapy but was no longer getting any range of motion to her lower extremities. On 6/12/24 at 2:42 p.m., Resident 79's clinical record was reviewed. The diagnoses included, but were not limited to, tibia (shin bone) fracture, fall, muscle weakness, and difficulty in walking. The care plan, dated 8/29/23 and current through target date of 6/30/24, indicated Resident 79 needed assistance with activities of daily living. The care plan lacked documentation of active or passive range of motion or any services to prevent further decrease in range of motion. The Occupational Therapy Discharge Summary, dated 1/15/24 at 1:21 p.m., indicated recommendations of home exercise program. The Functional Abilities and Goals Assessment, dated 5/16/24 at 10:11 a.m., indicated Resident 79 had functional limitation of range of motion on one side of her lower extremities. The Quarterly MDS assessment, dated 5/16/24, indicated Resident 79 had moderately impaired cognition, had limited range of motion on one side of her lower extremities, and was not on an active or passive range of motion restorative program. During an interview on 6/12/24 at 2:59 p.m., CNA 1 indicated Resident 79 had a broken leg and was no longer on therapy caseload. Resident 79 was not on a restorative program because they did not have a restorative program. During an interview on 6/13/24 10:50 a.m., COTA 1 indicated the Occupational Therapy Discharge Summary, dated 1/15/24, indicated to discharge Resident 79 to a home exercise program because the facility did not have an active or passive restorative program. During an interview on 6/13/24 at 12:05 p.m., the DHS indicated Resident 79 did not have a nursing restorative program or any services to prevent further decrease in range of motion of her lower extremity. On 6/13/24 at 3:04 p.m., the DHS provided the facility policy, Prevention of Decline in Range of Motion, undated, and indicated it was the policy currently being used by the facility. A review of the policy indicated, .b. The facility will provide treatment and care in accordance with professional standards of practice. this include, but is not limited to: 1. Appropriate services (specialized rehabilitation, restorative, and maintenance) .iii. Assistance as needed (active assisted, passive, supervision) . 3.1-42(a)(2)

Based on observation, interview and record review, the facility failed to ensure an open vial of insulin contained an open date for 1 of 1 resident reviewed for insulin during medication administration. (Resident 60) Findings include: During medication administration on 6/13/24 at 11:51 a.m., RN 1 was observed to remove an open vial of Humalog (insulin) from the medication cart and administer 2 units of insulin to Resident 60. The vial of Humalog was not observed to have an open date. Resident 60's clinical record was reviewed on 6/13/24 at 12:00 p.m. The diagnosis included, but was not limited to, type 2 Diabetes Mellitus. Physician orders, dated 6/13/24, for Resident 60 indicated . Humalog Injection Solution 100 unit/ml [milliliters] inject per sliding scale . During an interview on 6/13/24 at 11:53 a.m., RN 1 indicated the insulin was good for 90 days after it was opened and should have had an open date listed on the bottle. On 6/13/24 at 2:50 p.m., the Administrator provided the facility's policy,Labeling of Medications and Biologicals undated, and indicated it was the policy currently being used by the facility. A review of the policy indicated, . 8. Labels for multi-use vials must include: a. The date the vial was initially opened or accessed [needle punctured] . 3.1-25(j)

Based on interview and record review, the facility failed to ensure laboratory services were provided for a resident with an order to obtain a blood draw every six months for 1 of 5 residents reviewed for unnecessary medications. (Resident 67) Findings include: Resident 67's clinical record was reviewed on 6/11/24 at 2:13 p.m. The diagnoses included, but were not limited to, lymphedema and fracture of the femur. Physician orders, dated 5/1/24 through 5/31/24, for Resident 67 indicated . cbc [complete blood count] with diff [differential] and bmp [basic metabolic panel] every 6 months due to HTN [hypertension] and CHF [congestive heart failure] . A review of the lab report dated 5/16/24 at 7:30 a.m., for Resident 67 indicated a CBC and BMP was attempted however the lab technician was unable to obtain an adequate sample for testing. A second phlebotomist would be sent. The clinical record lacked documentation of labs being completed on 5/16/24 nor a second attempt being made by another phlebotomist. During an interview on 6/13/24 at 12:13 p.m., the Nurse Practitioner indicated the labs from 5/16/24 were part of the admission follow up labs and the company providing the lab service did not come back to draw the labs. On 6/13/24 at 2:50 p.m., the Administrator provided the facility's policy,Laboratory Services and Reporting undated, and indicated it was the policy currently being used by the facility. A review of the policy indicated, . 2. The facility is responsible for the timeliness of the services . 3.1-49(a)

Based on interview and record review, the facility failed to ensure the written notification required for a transfer and discharge was provided to the resident and the resident representative for 3 of 3 residents reviewed for hospitalization . (Resident 67, Resident 94, Resident 15) Findings include: 1. Resident 67's clinical record was reviewed on 6/11/24 at 2:13 p.m. The diagnoses included, but were not limited to, lymphedema and fracture of the femur. Resident 67's progress notes indicated the resident was sent to the hospital on 2/19/24. The clinical record lacked documentation of written notification of the Notice of Transfer and Discharge forms having been provided to the resident and the resident representative. 34848 2. On 6/13/24 at 11:46 a.m., Resident 94's clinical record was reviewed. The diagnoses included, but were not limited to, heart failure and atrial fibrillation (a rapid and irregular heartbeat of the heart's upper chambers). A 3/16/24 progress note indicated the resident was sent to the hospital at 7:07 a.m., due to a critical digoxin lab (a test measures the amount of the heart medicine digoxin in the blood) result. The clinical record lacked documentation of written Notice of Transfer and Discharge forms having been provided to the resident and the resident representative. 36912 3. On 6/11/23 at 11:15 a.m., Resident 15's clinical record was reviewed. The diagnoses included, but were not limited to, epileptic spasms and unspecified intellectual disabilities. The resident was transferred to the hospital on 5/1/24. There was no documentation to indicate the resident and/or the resident's representative were notified of this transfer in writing. On 6/12/24 at 1150 a.m., the Administrator provided the facility's policy,Holding Bed Space undated, and indicated it was the policy currently being used by the facility. A review of the policy did not indicated sending the resident and resident representative a copy of the Transfer and Discharge form in writing . During an interview on 6/13/24 at 10:50 a.m., the facility Administrator indicated the transfer/discharge form was not provided to the resident or resident's representative in writing for the hospital transfer. 3.1-12(a)(6)(A)(i) 3.1-12(a)(6)(A)(iii)

Based on interview and record review, the facility failed to ensure the notification of the bed-hold policy required for a resident who transferred to the hospital was provided in writing to the resident or the resident representative for 3 of 3 residents reviewed for hospitalization . (Resident 67, Resident 94, Resident 15) Findings include: 1. Resident 67's clinical record was reviewed on 6/11/24 at 2:13 p.m. The diagnoses included, but were not limited to, lymphedema and fracture of the femur. Resident 67's progress notes indicated the resident was sent to the hospital on 2/19/24. The clinical record lacked documentation of written notification which specified the facility's bed-hold policy having been provided to the resident or the resident representative. 34848 2. On 6/13/24 at 11:46 a.m., Resident 94's clinical record was reviewed. The diagnoses included, but were not limited to, heart failure and atrial fibrillation (a rapid and irregular heartbeat of the heart's upper chambers). A 3/16/24 progress note, indicated the resident was sent to the hospital at 7:07 a.m., due to a critical digoxin lab (a test measures the amount of the heart medicine digoxin in the blood) result. The clinical record lacked documentation of written notification which specified the facility's bed-hold policy having been provided to the resident or the resident representative. 36912 3. On 6/11/23 at 11:15 a.m., Resident 15's clinical record was reviewed. The diagnoses included, but were not limited to, epileptic spasms and unspecified intellectual disabilities. The resident was transferred to the hospital on 5/1/24. There was no documentation to indicate the resident and/or the resident's representative were notified of the facility bed hold policy in writing. During an interview on 6/13/24 at 10:15 a.m., the Administrator indicated the facility did not provide the resident nor the resident representative the notification of Bed-Hold forms in writing. The facility sent the forms with the resident when they transfer to another facility. On 6/12/24 at 1150 a.m., the Administrator provided the facility's policy,Holding Bed Space undated, and indicated it was the policy currently being used by the facility. A review of the policy indicated, 1. Upon admission and when a resident is transferred for hospitalization or for therapeutic leave . the business office will provide information concerning our bed-hold policy to the resident and the resident representative . 3.1-12(a)(25) 3.1-12(a)(26)

Based on record review and interview, the facility failed to ensure a resident's Minimum Data Set assessment was electronically transmitted to the Center for Medicare and Medicaid Services system within 14 days of the final completion date for 1 of 1 residents reviewed for Resident . (Resident 12) Finding includes: On 6/13/24 at 10:00 a.m., Resident 12's clinical record was reviewed. The diagnoses included, but were not limited to, chronic respiratory failure and anemia. The Discharge Minimum Data Set (MDS) assessment, dated 12/31/23, indicated the assessment was completed but not transmitted to the Center for Medicare and Medicaid Services system within 14 days of the completion date. During an interview on 6/13/24 at 3:25 p.m., the MDS Coordinator indicated the Discharge MDS assessment was not transmitted to the Center for Medicare and Medicaid Services system within 14 days of the completion date.

Based on interview and record review, the facility failed to ensure residents received an accurate Minimum Data Set (MDS) assessment, reflective of the resident's status at the time of the assessment for 2 of 22 residents reviewed for accuracy of assessments. (Resident 67, Resident 92) Findings include: 1. On 6/11/24 at 2:51 p.m., Resident 67's clinical record was reviewed. The diagnoses included, but were not limited to, anxiety and depression. The Quarterly Minimum Data Set (MDS) assessment, dated 4/24/24, indicated the resident did not have an anxiety diagnosis. A review of the resident's current June, 2024, orders indicated on 4/10/24, the resident was prescribed lorazepam (an anti-anxiety medication) 0.5 milligrams, 3 times a day, for anxiety. During an interview on 6/13/24 at 11:55 a.m., the MDS Coordinator indicated the resident's MDS assessment was coded incorrectly and it should have reflected a diagnosis of anxiety. 2. On 6/13/24 at 3:15 p.m., Resident 92's clinical record was reviewed. The diagnoses included, but were not limited to, congestive heart failure and hypertension. The Discharge MDS assessment, dated 5/18/24, indicated the resident was discharged to a critical access hospital. A nursing note, dated 5/18/24 at 2:52 p.m., indicated the resident was discharged and transported to a different skilled nursing facility. During an interview on 6/13/24 at 3:53 p.m., the MDS coordinator indicated the resident's MDS assessment was coded incorrectly. 3.1-31(d)

Based on observation, interview, and record review, the facility failed to develop a comprehensive care plan for a resident with behaviors for 1 of 1 residents observed for behaviors. (Resident 60) Findings include: On 6/9/24 at 12:16 p.m., Resident 60 was observed to be sitting in the dayroom in a recliner. The resident was attempting to stand up and was yelling out, I'm gonna die. On 6/10/24 at 10:26 a.m., Resident 60 was observed to be sitting in the dayroom in a recliner. The resident was attempting to stand up and was yelling out, I'm gonna die. On 6/10/24 at 2:10 p.m., Resident 60 was observed to be sitting in the dayroom in a recliner. The resident was attempting to stand up and was yelling out, I'm gonna die. On 6/11/24 at 12:23 p.m., Resident 60 was observed to be sitting in the dayroom in a recliner. The resident was attempting to stand up and was yelling out, help me, I'm gonna die. On 6/12/24 at 11:23 a.m., Resident 60 was observed to be sitting in the dayroom in a recliner. The resident was yelling out, I'm gonna die. On 6/13/24 at 9:40 a.m., Resident 60 was observed to be sitting in the dayroom in the recliner yelling out, help me, I will die. On 6/13/24 at 9:40 a.m., Resident 60 was observed to be sitting at the dining room table in a wheelchair. The resident was observed to be yelling, I will die while the Activity Director was observed to be helping the resident eat some string cheese. Resident 60's clinical record was reviewed on 6/13/24 at 12:00 p.m. The diagnosis included, but was not limited to, anxiety disorder. Physician orders, dated 6/13/24, for Resident 60 indicated . ativan [anti-anxiety medication] oral tablet 0.5 mg [milligrams] give 1 tablet by mouth three times a day for anxiety . The Admission Minimum Data Set (MDS) assessment, dated 4/18/24, assessed Resident 60 as having behavioral symptoms directed toward others to be occurring daily and behavior symptoms not directed toward others as occurring 1-3 days during the 7 day look back period. A review of the care plans on 6/13/24 at 1:35 p.m., for Resident 60 indicated the resident did not have a care plan for exhibiting behaviors. During an interview on 6/13/24 at 12:00 p.m., RN 1 indicated Resident 60 constantly exhibited behaviors and they made attempts to redirect and reassure her when she was upset and yelling out. During an interview on 6/13/24 at 3:04 p.m., the Social Services Assistant indicated Resident 60 did not have a care plan for behaviors but probably should have one in place. 3.1-35(a)

Based on observation, interview, and record review, the facility failed to provide sufficient staffing in order to provide adequate supervision to prevent repeated falls which resulted in major injury for 1 of 6 residents reviewed for accidents. (Resident 57) Findings include: On 4/28/2021 from 1:57 p.m. to 2:10 p.m., Resident 57 was observed to be walking around Unit 1 with a Merry Walker (an adaptation used to allow for freedom of movement without being restricted to walking with someone assisting them). Staff were observed not to be near the resident nor supervising. On 4/29/2021 from 11:03 a.m. to 11:20 a.m., Resident 57 was observed to be walking around Unit 1 and was unsteady on her feet. Staff were observed not to be near the resident nor supervising. On 4/29/2021 at 11:36 a.m., Resident 57's clinical record was reviewed. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set assessment, dated 12/9/2020, indicated Resident 57 was not interviewable, required limited assistance of 1 for locomotion on unit, was not steady during walking, had 1 fall with injury since admission, and had a behavior of wandering. The Fall Risk Assessment Custom, dated 11/24/2020 at 1:45 p.m., indicated Resident 57 was a high risk for falls, had 3 or more falls in the past 3 months, and had a balance problem while walking. A care plan, initiated on 11/24/2020 and current through target date of 6/1/2021, for Resident 57 indicated, . Focus: Potential for falls related to dementia, [CONDITION(S)] [hypertension] with antihypertensive use, need for assist with bed mobility, transfers, toileting, [CONDITION(S)], antipsychotic use, dry eye syndrome, [CONDITION(S)], [CONDITION(S)], [CONDITION(S)], psychotic disorder, extrapyramidal movement . Goal: Will not experience major injury from falling through next review. The care plan for Resident 57 lacked documentation for implementation of an intervention for staff supervision to prevent a reoccurrence of falls. A review of the following 11 Fall Investigation Reports for Resident 57 indicated : On 11/27/2020 at 5:15 a.m., the resident was found by a Certified Nursing Assistant (CNA) in another resident's room, laying on her back between the hallway and the bathroom door. Two lacerations (deep skin tear) were found on the back of the resident's head. Staff were unable to obtain measurements due to bleeding. The resident was sent to the emergency room . No witnesses found (was not observed by staff). Hospital Discharge Instructions, dated 11/28/2020, for Resident 57 indicated, . Reason for Your Visit: Fall . Your Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . On 12/6/2020 at 2:54 p.m., the resident was found by a CNA on the floor laying on her back by the bed in her room. A skin tear was found on her left elbow. No witnesses found. On 1/9/2021 at 12:56 a.m., the resident wandered around and fell . Staff were unable to determine injury to left antecubital (area to the front of the elbow). No witnesses found. On 1/25/2021 at 12:00 p.m., the resident was in the main dining room and reached over a table, lost her balance, and fell on to the floor onto her left hip. No witnesses found. On 1/30/2021 at 10:00 a.m., a CNA alerted the nurse Resident 57 was found laying on the floor in a co-resident's room. The CNA reported the resident had been in a prone position (face down), on the floor, when found. No witnesses found. On 2/1/2020 at 7:40 p.m., observed the resident on the floor next to their bed and mattress extenders. No witnesses found. On 2/26/2021 at 7:41 p.m., a CNA walked into the resident's room, found Resident 57 in the floor sitting with their back against the mattress extenders. A Skin tear to the left elbow was observed. No witnesses found. On 3/13/2021 at 7:25 a.m., the resident was found laying on floor, in their room, and in a prone position. No witnesses found On 3/13/2021 at 8:15 a.m., the resident was found in the doorway of an empty room, laying on their left side. No witnesses found. On 4/1/2021 at 12:21 a.m., the resident wandered out of their room into another resident's room and fell in the doorway of the other resident's bathroom. A skin tear on left elbow was observed. No witnesses found. On 4/5/2021 at 7:25 p.m., a CNA alerted the nurse she had opened the door and exited out of another resident's room, from putting the other resident to bed. Resident 57 was on the ground in the hallway and had just fallen. The nurse assessed the resident and observed a laceration above the right eye and a laceration on the left thumb. The resident yelled out in pain when staff tried to be turn the resident onto her back. The resident indicated the pain was felt in her right hip. The resident was taken to the hospital. No witnesses found. Hospital Radiology Report, dated 4/5/2021 at 9:20 p.m., for Resident 57's pelvis and left hip indicated, no left hip fracture or dislocation and the left proximal femur (upper leg bone) was intact (no fracture indicated). A review of Progress Notes for Resident 57 indicated the following: On 4/10/2021 at 4:53 p.m., therapy screened Resident 57 due to a recent fall and aides reported a decline in the resident's ability to walk and transfer between surfaces. On 4/12/2021 at 7:46 a.m., assessed resident at that time due to increased pain. The resident showed signs and symptoms of pain in the left hip and was unable to bear weight and showed pain in the right shoulder. Resident 57, yelling out in pain. On 4/12/2021 at 9:16 a.m., the physician ordered a new order for STAT (immediate) hip/pelvis x-ray. Hospital Radiology Report, dated, 4/12/2021 at 5:00 p.m., indicated, . INDICATION: Fall 6 days ago. Now not ambulating [walking] . FINDINGS: There are fractures of the right superior and inferior pubic rami [pelvic bone] . On 5/3/2021 at 11:30 a.m., the Director of Nursing (DON) provided the staffing schedules for 11/26/2020 and 4/5/2021. Unit 1, where Resident 57 resided and where she sustained major injuries on the above dates, indicated on 11/26/2020, 2 CNA's on duty for the night shift (6:00 p.m. to 6:00 a.m.) and 1 nurse (6:30 p.m. to 6:00 a.m.). On 4/5/2021, 1 CNA and 1 nurse on duty for the night shift (6:00 p.m. to 6:00 a.m.) Unit 1 had a census of 25 residents during the survey period and is a a secured memory unit. The most current MDS reviews indicated 5 residents on Unit 1 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview, on 4/30/2021 at 10:41 a.m., CNA 1 indicated on the weekend day shift, Unit 1 would have 2 CNA's and 2 nurses but 1 nurse leaves at 10:00 a.m. The residents should be supervised when walking the hall. During an interview, on 4/30/2021 at 11:39 a.m., Licensed Practical Nurse (LPN) 1 indicated, Unit 1 has 2 CNA's and 1 nurse on night shift, but 1 CNA leaves at 10:00 p.m. and that leaves them short at times. During an interview, on 4/30/2021 at 12:22 p.m., CNA 2 indicated Unit 1 would have 2 CNA's and 1 nurse or QMA (Qualified Medication Aide). Some residents required 2 staff members to provide care in the room and during those times they were unable to supervise residents. During an interview, on 4/30/2021 at 4:15 p.m., CNA 3 indicated Resident 57 liked to wander the hallways. They tried to watch her closely, but there were times they got busy with other residents and were unable to supervise what she was doing. During an interview, on 5/3/2021 at 11:43 a.m., the DON indicated 7 residents required 2 staff members in the room during personal care. On 4/30/2021 at 3:30 p.m., the Director of Nursing provided the facility's policy, Staffing with a revised date of 10/2017, and indicated this was the policy currently being used by the facility. A review of the policy indicated, . Our facility provides sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with resident care plans and the facility assessment . 3.1-17(a)

Based on observation, interview, and record review, the facility failed to provide supervision to prevent repeated falls for a resident assessed to be a high risk for falls and who wandered resulting in two unwitnessed falls with injury that required acute care medical intervention for 1 of 6 residents reviewed for accidents (Resident 57), the facility failed to ensure implementation of a fall care plan intervention for 1 of 6 residents reviewed for accidents (Resident 20), and the facility failed to ensure full sharps containers kept in a soiled utility room were inaccessible, an unlocked and unattended lab cart containing syringe needles was inaccessible, an unlocked and unattended treatment cart containing syringe needles was inaccessible, and toilet bowel cleaner and surface cleaner were inaccessible for 5 independently and cognitively impaired ambulatory (mobile) residents of 25 residents residing on the 300 and 400 units. Findings include: 1. On 4/28/2021 from 1:57 p.m. to 2:10 p.m., Resident 57 was observed to be walking around Unit 1 with a Merry Walker (an adaptation used to allow for freedom of movement without being restricted to walking with someone assisting them). Staff were observed not to be near the resident nor supervising. On 4/29/2021 from 11:03 a.m. to 11:20 a.m., Resident 57 was observed to be walking around Unit 1 and was unsteady on her feet. Staff were observed not to be near the resident nor supervising. On 4/29/2021 at 11:36 a.m., Resident 57's clinical record was reviewed. Diagnoses included, but were not limited to Alzheimer's disease and [CONDITION(S)] (swelling and stiffness of bone joints that can cause a decrease in range of motion). The Admission Minimum Data Set assessment, dated 12/9/2020, indicated Resident 57 was not interviewable, required limited assistance of 1 for locomotion on unit, was not steady during walking, had 1 fall with injury since admission, and had a behavior of wandering. The Fall Risk Assessment Custom, dated 11/24/2020 at 1:45 p.m., indicated Resident 57 was a high risk for falls, had 3 or more falls in the past 3 months, and had a balance problem while walking. A care plan, initiated on 11/24/2020 and current through target date of 6/1/2021, for Resident 57 indicated, . Focus: Potential for falls related to dementia, [CONDITION(S)] [hypertension] with antihypertensive use, need for assist with bed mobility, transfers, toileting, [CONDITION(S)], antipsychotic use, dry eye syndrome, [CONDITION(S)], [CONDITION(S)], [CONDITION(S)], psychotic disorder, extrapyramidal movement . Goal: Will not experience major injury from falling through next review . Interventions: Assist with bed mobility, transfers, and toileting as indicated. Created 11/24/2020. Attempt offer activities during episodes of wandering. Created 12/1/2020. Attempt to assist [resident name] with toileting and to bed at night during episodes of wandering. Created 1/20/2021. Attempt to keep environment free of clutter. Created 11/24/2020. Attempt to use distraction techniques frequently when restless. Created 4/5/2021. Attempt/encourage [resident name] to take [MEDICATION(S)] medication as ordered by MD/NP [medical doctor/nurse practitioner]. Created 4/1/2021. Attempt/encourage resident to sit in recliner during day to prevent fatigue. Created 3/15/2021. Bed against wall. Created 1/20/2021. Encourage [resident name] to remain in common areas during waking hours. Created 2/2/2021. Encourage [resident name] to wear nonskid socks/shoes. Created 11/24/2020. Have commonly used articles within easy reach. Created 11/24/2020. Keep call light within reach when in room. Created 11/24/2020. May have night light. Created 1/20/2021. May have soft touch call light within reach. Created 2/4/2021. Offer activities when wandering. Created 4/30/2021. Provide toileting opportunities as needed and check for incontinence. Created 11/24/2020. Reinforce need to use call light for assistance. Created 11/24/2020. Review fall risk and need for interventions quarterly and post fall. Created 11/24/2020. Scoop mattress. Created 3/4/2021 . The care plan for Resident 57 lacked documentation for implementation of an intervention for staff supervision to prevent a reoccurrence of falls. A review of the following 11 Fall Investigation Reports for Resident 57 indicated : On 11/27/2020 at 5:15 a.m., the resident was found by a Certified Nursing Assistant (CNA) in another resident's room, laying on her back between the hallway and the bathroom door. Two lacerations (deep skin tear) were found on the back of the resident's head. Staff were unable to obtain measurements due to bleeding. The resident was sent to the emergency room . No witnesses found (was not observed by staff). Hospital Discharge Instructions, dated 11/28/2020, for Resident 57 indicated, . Reason for Your Visit: Fall . Your Diagnosis: Nontraumatic subarachnoid hemorrhage, unspecified [brain bleed] and subdural hematoma [collection of blood] . On 12/6/2020 at 2:54 p.m., the resident was found by a CNA on the floor laying on her back by the bed in her room. A skin tear was found on her left elbow. No witnesses found. On 1/9/2021 at 12:56 a.m., the resident wandered around and fell . Staff were unable to determine injury to left antecubital (area to the front of the elbow). No witnesses found. On 1/25/2021 at 12:00 p.m., the resident was in the main dining room and reached over a table, lost her balance, and fell on to the floor onto her left hip. No witnesses found. On 1/30/2021 at 10:00 a.m., a CNA alerted the nurse Resident 57 was found laying on the floor in a co-resident's room. The CNA reported the resident had been in a prone position (face down), on the floor, when found. No witnesses found. On 2/1/2020 at 7:40 p.m., observed the resident on the floor next to their bed and mattress extenders. No witnesses found. On 2/26/2021 at 7:41 p.m., a CNA walked into the resident's room, found Resident 57 in the floor sitting with their back against the mattress extenders. A Skin tear to the left elbow was observed. No witnesses found. On 3/13/2021 at 7:25 a.m., the resident was found laying on floor, in their room, and in a prone position. No witnesses found On 3/13/2021 at 8:15 a.m., the resident was found in the doorway of an empty room, laying on their left side. No witnesses found. On 4/1/2021 at 12:21 a.m., the resident wandered out of their room into another resident's room and fell in the doorway of the other resident's bathroom. A skin tear on left elbow was observed. No witnesses found. On 4/5/2021 at 7:25 p.m., a CNA alerted the nurse she had opened the door and exited out of another resident's room, from putting the other resident to bed. Resident 57 was on the ground in the hallway and had just fallen. The nurse assessed the resident and observed a laceration above the right eye and a laceration on the left thumb. The resident yelled out in pain when staff tried to be turn the resident onto her back. The resident indicated the pain was felt in her right hip. The resident was taken to the hospital. No witnesses found. Hospital Radiology Report, dated 4/5/2021 at 9:20 p.m., for Resident 57's pelvis and left hip indicated, no left hip fracture or dislocation and the left proximal femur (upper leg bone) was intact (no fracture indicated). A review of Progress Notes for Resident 57 indicated the following: On 4/10/2021 at 4:53 p.m., therapy screened Resident 57 due to a recent fall and aides reported a decline in the resident's ability to walk and transfer between surfaces. On 4/12/2021 at 7:46 a.m., assessed resident at that time due to increased pain. The resident showed signs and symptoms of pain in the left hip and was unable to bear weight and showed pain in the right shoulder. Resident 57, yelling out in pain. On 4/12/2021 at 9:16 a.m., the physician ordered a new order for STAT (immediate) hip/pelvis x-ray. Hospital Radiology Report, dated, 4/12/2021 at 5:00 p.m., indicated, . INDICATION: Fall 6 days ago. Now not ambulating [walking] . FINDINGS: There are fractures of the right superior and inferior pubic rami [pelvic bone] . During an interview, on 4/30/2021 at 10:41 a.m., CNA 1 indicated Resident 57 liked to wander the halls and could be unsteady on her feet. The resident should have been supervised when walking the hall. During an interview, on 4/30/2021 at 11:39 a.m., Licensed Practical Nurse (LPN) 1 indicated she had worked the shift when Resident 57 fell on [DATE]. The fall was unwitnessed. The two CNA's were in another resident's room and when they came out of that room, Resident 57 was in the middle of falling. This happened in the front hallway and Resident 57's room was in the back hallway. She liked to wander the hallways and was supposed to be supervised. The resident had complained of pain when they tried to roll her over. During an interview, on 4/30/2021 at 12:22 p.m., CNA 2 indicated she had worked the shift when Resident 57 fell on [DATE] and 4/5/2021. She did not witness the falls. The resident liked to wander the halls and would sometimes trip over her feet. On 11/27/2020, her and another CNA were in a resident's room when they heard Resident 57 making a moaning noise. They found Resident 57 in another resident's room on the floor. They were unable to determine how she fell . The fall was unwitnessed. The room they found her in was in the front hallway and her room was in the back hallway. The resident had blood on her head. She was sent to the emergency room . On 4/5/2021, her and another CNA were in a resident's room and when they came out into the hallway, Resident 57 was falling. They were unable to stop the fall. The resident was in the front hallway. She had a laceration over her right eye and was protecting her hip as if she were in pain. She was sent to the emergency room , but they didn't find any injuries. When she came back she was still acting as if she were in pain. The facility performed another x-ray and found she had a fracture. During an interview, on 4/30/2021 at 4:15 p.m., CNA 3 indicated Resident 57 liked to wander the hallways. They tried to watch her closely, but there were times they got busy and were unable to supervise what she was doing. On 4/30/2021 at 3:30 p.m., the Director of Nursing provided the facility's policy, Assessing Falls and Their Causes with a revised date of 3/2018, and indicated this was the policy currently being used by the facility. A review of the policy did not address implementing an intervention of supervision for a resident with repeated falls. 2. On 4/28/21 at 10:20 a.m., Resident 20 was observed to be laying on the couch in the day room with no mat on the floor beside the couch. On 4/28/21 at 11:05 a.m. Resident 20 was observed to be laying on the couch in the day room with a helmet on with no mat beside the couch. On 4/28/21 at 2:09 p.m., Resident 20 was observed to be sitting on the couch in the day room interacting with the staff with no mat on the floor beside the couch. On 4/30/21 at 9:44 a.m., Resident 20 was observed to be laying on the couch with a gait belt on around his waist and a helmet on, with no mat beside the couch. On 5/03/21 at 10:25 a.m., Resident 20 was observed to be sitting on couch in the day room with a helmet on with the no mat beside the couch. On 4/30/21 10:01 a.m., Resident 20's clinical record was reviewed. The diagnoses included, but were not limited to, [CONDITION(S)] disorder, profound intellectual disabilities, anxiety, and [CONDITION(S)] (seizures). The annual Minimum Data Set (MDS) assessment, dated 2/8/21, indicated Resident 20 had short term memory problem, required extensive assistance of two or more with transfers, had 2 or more fall with no injury, and had 2 or more falls with minor injury. Resident 20's Fall Risk Assessment, dated 2/8/21, indicated a high risk for falls. Resident 20's progress notes indicated the following: -On 2/15/21 at 7:05 a.m., Resident 20 was laying on the couch in the common area. His head was bleeding from a laceration above his left eye. Resident 20 was sent to the emergency room for treatment. -On 2/15/21 at 9:30 a.m., Resident 20 returned from the hospital with Dermabond (medical skin adhesive) applied to the laceration above left eyebrow. Resident 20's IDT (interdisciplinary team) At Risk form indicated the following: -On 2/18/21 at 2:09 p.m., the identified risk was a fall on 2/16/21. The interventions implemented were mat on the floor next to couch. The IDT recommendations were to continue with current interventions. -On 2/26/21 at 7:59 a.m., the identified risk was a fall on 2/16/21. The interventions implemented were mat on the floor next to couch. The IDT recommendations were to continue with current interventions. -On 3/5/21 at 8:14 a.m., the identified risk was a fall on 2/16/21. The interventions implemented were mat on the floor next to couch. The IDT recommendations were to continue with current interventions. A care plan, initiated on 4/15/10 and current through target dated 5/5/21, for Resident 20 indicated: .Focus .[Resident name] has potential for falls r/t [related to] cognitive mobility and communication deficits, has dx [diagnoses] [CONDITION(S)] and impulse disorder, receives [CONDITION(S)], cardiac and pain meds [medications] and needs variable assist with ADLs [Activities of Daily Living] .Goal: [Resident name] will remain free of falls/injury R/T [related to] falls. The fall care plan lacked the mat on the floor next to couch as an intervention. Resident 20's progress notes lacked documentation of a mat on the floor next to the couch as an ineffective intervention for falls or Resident 20 pushing away the mat next to the couch. During an interview, on 4/29/21 at 10:15 a.m., Qualified Medication Aid (QMA) 1 indicated Resident 20 had history of falls with injuries such as head laceration. His fall interventions were to wear a helmet, to wear a gait belt while ambulating, and staff to provide supervision with ambulation. During an interview, on 4/29/21 at 10:45 a.m., CNA 4 Resident 20 had history of falls. His fall interventions were to provide supervision while ambulating and to wear a helmet. During an interview, on 4/30/21 at 10:55 a.m., Licensed Practical Nurse (LPN) 2 indicated Resident 20 had frequent falls. Some falls required treatment at the emergency room for head lacerations. His fall interventions were to wear a helmet and for 15 min checks. During an interview, on 4/30/21 at 3:35 p.m., the Director of Nursing (DON) indicated the interventions implemented on the IDT At Risk form would be interventions on the care plan. If the interventions were ineffective, it would be documented in the progress notes. During an observation with the Assistant Director of Nursing (ADON), on 4/30/21 at 3:45 p.m., the ADON indicated the mat for Resident 20 was behind the couch. Resident 20 will push the mat away from the couch. The IDT fall interventions implemented would be interventions on the resident's care plan. On 4/30/21 at 4:00 p.m., the DON provided the facility's policy, Assessing Falls and Their Causes, dated March 2018, and indicated it was the policy currently being used by the facility. A review of the policy indicated, .6. Appropriate interventions taken to prevent future falls . 3a. On 4/26/21, from 10:05 AM to 10:20 AM the soiled linen room on the 300 unit was found with keys in the door lock, giving access to the room. No staff were present in the area. Inside the room was a trash container with a red hazardous materials bag. In the bag were 3 sharps containers, containing used needles. 3b. On 4/26/21, from 10:22 A.M. to 11:00 A.M., and on 4/27/21, from 10:05 A.M. to 11:25 A.M., room 412 was observed to be unlocked and unattended by staff. Inside the room was an unlocked treatment cart with a key in the lock. In the bottom drawer of the cart were two 100 unit boxes of syringe needles. In the closet were two containers of toilet bowl cleaner, upon which the labels stated, .do not swallow ., and 2 containers of surface cleaner, upon which the labels stated, .do not swallow . 3c. On 4/26/21, from 12:30 P.M. to 1:00 P.M., the lab cart on the 400 unit side of the Willow nursing station was observed to be unlocked and unattended by staff. Two containers on the cart contained blood draw needles. During an interview, on 4/26/21 at 10:21 A.M., the 300 unit manager indicated the keys to the soiled utility room were not to be in the door, and the door was to be locked at all times, due to the room containing soiled and hazardous materials. During an interview, on 4/26/21 at 1:00 P.M., the facility Administrator indicated the treatment cart in room 412 should have been locked, and the key removed, and the toilet bowl cleaner and surface cleaner should have been removed from the closet. The lab cart with accessible syringe needles should have been locked and placed in a secure location. On 4/29/21, at 11:10 A.M., the facility Administrator provided a list of independently ambulatory and mobile residents in the facility. A review of the list indicated there were 13 independently ambulatory or mobile residents in the facility residing on the 300 and 400 units. On 4/29/21, at 11:15 A.M., the facility Administrator provided the Resident Bill of Rights, undated. A review of the Resident Bill of Rights indicated, .the facility must provide .a safe, clean, comfortable, and home-like environment . 3.1-45(a)(1) 3.1-45(a)(2)

Based on observation, interview, and record review, the facility failed to ensure residents were free from abuse from another resident with assessed physical aggression behavior (Resident B), which resulted in a resident being choked and a resident being hit for 2 of 2 residents reviewed for abuse (Resident C and Resident D). Findings include: On 2/22/21 at 10:31 a.m., Resident B was observed to be calmly laying on a couch watching television in the orange room (an area to provide Resident B a quiet space). Interview, at that time, Resident B indicated he was moving to California next week to live with his family. On 2/23/21 at 11:30 a.m., Resident B's clinical record was reviewed. The [DIAGNOSES REDACTED]. [MEDICAL CONDITION] and mood disorder), and [MEDICAL CONDITION] disorder. Resident B's quarterly Minimum Data Set (MDS) assessment, dated 11/30/20, indicated he was cognitively intact, had physical behavior symptoms directed toward others 1 to 3 days of 7 days reviewed, required extensive assistance of one staff member for locomotion on the unit, and extensive assistance of 2 or more staff members for transfers, . A care plan, initiated on 3/5/20 and current through target date 2/28/21, for Resident B indicated: .Focus: .(Resident name) has physical aggression AEB (as evidence by): hitting and kicking staff or co residents .GOAL .(Resident name) will have no more than 2 episodes .INTERVENTIONS .Document all behaviors in PCC (electronic health record) under behavior progress note and in the behavior books, give (resident name) a pillow to hit to help relieve his frustration/anger, inform social service if increase in behavior, make sure resident is safe then leave and re-approach with a different caregiver if possible, and psych (psychiatry) consult as needed .(sic) Resident B's progress notes indicated the following: -On 2/1/21 at 11:28 a.m., Resident B was attempting to hit staff and others residents. The interventions attempted were to assist him back to his room and redirect resident. The interventions were not effective. -On 2/1/21 at 4:00 p.m., Resident B was cursing and threatening staff and other residents. The interventions attempted were to assist him back to his room and redirect resident. He continued to curse staff for awhile after being in his room and then he stopped. - On 2/2/21 at 12:31 p.m., Resident B was hitting and kicking staff, and was threatening other residents. The interventions attempted were to assist him to his wheelchair, assist him back to his room, redirection, one on one, and offer him food and drink. The interventions were not effective. -On 2/2/21 at 3:12 p.m., the nurse and Certified Nursing Assistant (CNA) heard someone slapping someone. They observed Resident B standing over Resident D (who was going into orange room from his own room). Resident B was slapping Resident D's face. Resident D was putting his arm up to attempt to block Resident B's slaps, but Resident B continued to slap Resident D. The nurse and the CNA assisted Resident B back to his room. Resident B continued to hit and cuss at staff. -On 2/2/21 at 3:13 p.m., Resident B was cussing and hitting staff. The interventions attempted were one on one and redirection. The interventions were not effective. -On 2/4/21 at 10:14 a.m., Resident B was transferred to psychiatric hospital and remained impatient from 2/4/21 to 2/15/21. Resident B's psychiatric hospital individualized Mental Health Safety Plan, dated 2/15/21, indicated to provide a pillow for hitting, a time out room to think, create a safe environment, just put me inside those doors and I won't hit anybody (which doors not indicated). Resident B's progress notes continued: -On 2/15/21 at 12:05 p.m., Resident B returned from the psychiatric hospital. -On 2/15/21 at 2:28 p.m. Resident C was standing in front of Resident B. Resident C put his hand on Resident B's wheelchair. Resident B hit Resident C's lower back. Resident B yelled at Resident C to move. -On 2/16/21 at 3:59 a.m. (late entry not indicated 2/15/21 after 6:00 p.m. / sic), a nurse was at the medication cart, when she noticed Resident D's feet and legs were flailing around as he was sitting in a recliner in the hallway. Resident B was standing in his doorway which was right in front of Resident D. She went to check on both of the residents. She noticed Resident B had Resident D by the front of his throat. With Resident B's one hand, he was squeezing. Resident D was struggling to get away. The nurse grabbed Resident B's hand and removed the hand from Resident D's throat. The nurse told Resident B that was unacceptable, and we never put our hands around someone like that because we can really hurt them. The nurse started helping Resident D up out of the recliner. Resident D had ahold of both of the nurse's hands, when Resident B started to smack Resident D in the face. Resident B struck him 3 times on the face. When the nurse told Resident B to stop hitting Resident D, Resident B stated he didn't care. The nurse was able to get Resident D out of reach of Resident B. The residents were separated. Resident D was noted to have red areas on the front right and left side of his throat. The nurse received an order to send Resident B to the emergency room for evaluation and treatment for [REDACTED]. Resident B's emergency room Progress Note, dated 2/15/21 at 8:08 p.m., indicated he presented to the emergency room after assaulting another resident. Resident B had been in his room at the facility when another resident came into his room on 3 different occasions and touched his possessions. Resident B told him to stop multiple times. Finally, Resident B indicated he would, slap him and choke him if he did not stop. The other resident continued to touch his things and Resident B hit the other resident several times. Resident B was discharged back to facility due to, he did not display any spontaneous violent or psychotic behavior and he agreed to abstain from any violent behavior, and was provided a prescription for [MEDICATION NAME] (antianxiety) give 0.5 mg three times a day as needed for agitation. Instructions were provided to allow Resident B to stay in his room uninterrupted to sleep. Resident B's clinical records from his emergency room visit dated 2/15/21 to current 2/23/21, indicated Resident B had been provided a quiet room/space and no resident altercations had occurred. On 2/23/21 at 1:00 p.m., Resident D's clinical record was reviewed. The [DIAGNOSES REDACTED]. Resident D's annual MDS assessment, dated 12/21/20, indicated he had long and short term memory impairment, required extensive assistance of one for locomotion on unit, and extensive assistance of 2 or more with transfers. Resident D's progress notes indicated the following: -On 2/2/21 at 2:51 p.m., a nurse and CNA heard someone slapping someone. They observed Resident D sitting on the floor in the orange room doorway with Resident B over the top of Resident D hitting him on the face. Resident D attempted to cover his face with his arms. Resident B continued to hit Resident D. Resident D's face was red, but was not bleeding. -On 2/16/21 at 4:09 a.m., a nurse was at the medication cart when she noticed Resident D's feet and legs were flailing around. Resident D was sitting in a recliner in the hallway. Resident B was standing in his doorway right in front of Resident D. Resident B had Resident D by the front of his throat with one hand. Resident D was struggling to get away. The nurse grabbed Resident B's hand from Resident D's throat. The nurse told Resident B that was unacceptable and we never put our hands around someone like that because we can really hurt them. Resident B yelled back at the nurse. The nurse started to help Resident D up out of the recliner. Resident D had ahold of both of the nurse's hands. Resident B started to smack Resident D hard on the face 3 times. The nurse told Resident B to stop hitting Resident D and he was hurting Resident D. Resident B indicated he didn't care. Resident D had a red area to his throat on the front right and left side. Resident D's progress notes lacked documentation of an injury after either incident. On 2/23/21 at 1:15 p.m., Resident C's clinical record was reviewed. The [DIAGNOSES REDACTED]. Resident C's annual MDS assessment, dated 2/18/21, indicated he had short-term memory impairment, extensive assistance of two or more staff for locomotion on unit, and extensive assistance of two or more staff for transfer. Resident C's progress notes, dated 2/15/21 at 2:39 p.m., indicated Resident C was standing in front of Resident B in the dining room. Resident C put his hands on Resident B's wheelchair. Resident B hit Resident C on the lower back. Resident C's progress notes lacked documentation of an injury after the incident. During an interview, on 2/19/21 at 2:45 p.m., the Director of Nursing (DON) indicated Resident B had a recent psychiatric hospital stay. Two hours after Resident B returned from hospital, he hit a resident, and then later that evening, he had his hand on the throat of another resident attempting to choke the resident. After these incidents, Resident B was moved to a room on a quiet hallway and an orange room to provide a calm environment for Resident B. The new room has helped keep Resident B calm. During an interview, on 2/22/21 at 11:45 a.m., the DON indicated Resident B was sent to the psychiatric hospital for physical aggression towards residents and staff. Last week, after Resident B returned from the psychiatric hospital, he wanted to phone his sister. Resident B told his sister he had hit someone at the facility. She asked him why did he hit someone, he told her he was mad. Prior to his hospital stay, he was upset and threw his remote at his television and broke it. Some of his physical aggression behavior interventions were to watch 80's television shows and activities. Resident B planned on moving to California to stay with family. During an interview, on 2/22/21 at 11:55 a.m., the Assistant Director of Nursing (ADON) indicated when she came to work on 2/15/21, Resident B had returned earlier from a psychiatric hospital stay, and he had hit another resident earlier in the day. When her shift started, Resident B was agitated. They had tried to offer snacks, magazines, and call his sister. The interventions worked for a little while. She observed Resident D legs over a recliner in the hallway. When she went to Resident D, she observed Resident B's hands on Resident D's throat. She immediately removed Resident B's hands from Resident D's throat, when Resident B started hitting Resident D. Resident B was sent to the emergency room , because he was a danger to self and others. During an interview, on 2/22/21 at 12:34 p.m., Licensed Practical Nurse (LPN) 1 indicated she working on 2/15/21, when Resident B returned from the psychiatric hospital. A couple of hours after he returned from the psychiatric hospital, Resident B was agitated with staff and residents. The interventions they tried were activities and to offer resident snacks. When Resident C went to stand up, he put his hand on the back of Resident B's wheelchair. Resident B was mad at Resident C, and Resident B hit Resident C. During an interview, on 2/23/21 at 10:30 a.m., CNA 1 indicated Resident B can be pleasant and talking with staff and residents, and with no triggers can be agitated and start hitting staff and residents. His physical aggression interventions are keep the resident safe, and give Resident B some quiet time and space. He has provided one on one supervision to keep residents safe. On 2/23/21 at 1:30 p.m., the Administrator indicated the facility did not have a policy to monitor the safety of the residents on a secured unit. On 2/23/21 at 1:30 p.m., the Administrator provided the facility's policy, Resident-to-Resident Altercations, dated December 2016, and indicated it was the policy currently being used by the facility. A review of the policy indicated, .2. If two residents are involved in an altercation, staff will: .b. Identify what happened, including what might have led to aggressive conduct on the part of one or more of the individuals involved in the altercation; d. Review the events with the Nursing Supervisor and Director of Nursing, and possible measures to try to prevent additional incidents: . This Federal tag relates to Complaint IN 724. 3.1-27(a)(1)

Based on interview and record review, the facility failed to ensure staff implemented two person assistance on a flat surface during ADL (activities of daily living) care which resulted in a [MEDICAL CONDITION] and surgery for [REDACTED]. Findings include: On 4/10/19 at 10:45 a.m., Resident B's clinical record was reviewed. [DIAGNOSES REDACTED]. Resident B's Quarterly MDS assessment, dated 1/10/19, indicated the resident was a 2 person extensive assist for bed mobility, transfer, dressing, toileting, and personal hygiene. A Brief Interview for Mental Status was not conducted, as the resident was rarely or never understood. The resident had an absence of spoken words, was sometimes able to make herself understood, and was sometimes able to understand others. A care plan, initiated on 12/8/09 and current through 7/7/19, for Resident B indicated, (Resident Name) is at risk for falls due to non wt (weight) bearing/impaired sit balance r/t (related to) cp ([MEDICAL CONDITION]) with contractures with functional limitations (to) all extremities . Interventions, initiated 1/12/13, revised 12/8/17 . Do not change resident in W/C (wheelchair) and Risk for skin alterations/development of pressure/IAD (incontinence associated [MEDICAL CONDITION]) areas due to impaired mobility and cognition, incont. (incontinent) of B/B (bowel and bladder) and requires assist with ADLS (activities of daily living) .Interventions, initiated 12/8/09, revised 4/3/19 .2 staff members using hoyer for transfers/repositioning to avoid shear/friction . A review of Resident B's progress notes indicated the following: -On 3/22/19 at 7:05 p.m., While the resident was being assisted with changing of brief, with assist of two, CNA's heard a loud pop emanating from left leg. CNAs were unable to precisely located origin . Resident began crying loudly, pointing to/smacking left leg. When questioned if in pain, resident nodded head yes and continued to point to left leg . x ray would be performed STAT (immediately) . -On 3/23/19 at 12:09 a.m., . received x ray results at 9:55 p.m. rec'd (received) n/o (new order) to send to (Hospital Name) ER (emergency room ) d/t (due to) femur fracture. 911 called sent to ER at 10:20 p.m. -On 3/23/19 at 2:57 a.m., (Hospital Name) called to let facility know that resident had been admitted with fx (fracture) femur into hip . -On 3/23/19 at 2:40 p.m., resident will be having surgery in the next couple of days to repair [MEDICAL CONDITION] . During an interview, on 4/10/19 at 3:00 p.m., CNA 2 indicated CNA 1 attempted to change Resident B's incontinence brief while the resident was lying in the reclined wheelchair. CNA 2, was preparing resident oral care items. CNA 1 was the only staff assisting the resident in changing of the resident's brief. CNA 1 had just begun the care and was assisting the resident in lifting her left leg when a popping sound was heard and CNA 1 called for the nurse on duty. During an interview, on 4/10/19 at 11:45 a.m., the Director of Nursing (DON) indicated CNA 1 attempted to change Resident B's incontinence brief, with no other assistance, while the resident was reclined in her wheelchair. CNA 2 was present, but not involved in the changing of the resident's brief. The resident was a 2 person assist, and the resident was not to be changed in the wheelchair, but was to be transferred to a flat surface such as the bed to be changed. CNA 1 was terminated from employment. On 4/10/19 at 11:50 A.M., the DON was asked for the facility's policy regarding ADL care for residents. The policy, Using a Mechanical Lifting Machine was provided by the DON on 4/10/19 at 2:13 P.M. No additional policy regarding ADL care was provided. This Federal tag relates to Complaint IN 007. 3.1-45(a)(2)

Based on observation, interview and record review the facility failed to ensure a resident at risk of falls, with a history of falls, care planned to be with staff when up in the wheelchair on 5/2/11, was sitting where staff could not get to the resident on 7/2/11 resulting in her sliding out of the chair with a resulting pelvic fracture, and then fell again while being toileted by a Certified Nursing Assistant on 8/22/11 who failed to utilize a gait belt, Resident #1, failed to ensure Resident #41 received timely interventions to prevent falls, resulting in an ankle fracture, for 2 of 8 residents reviewed for falls, in the sample of 24. Findings include: 1. Resident #1's was identified on the initial tour of the locked dementia unit, with the Director of Nursing, on 12/5/11 at 9:00 A.M. as cognitively impaired and having had falls in the facility. Resident #1 was observed on 12/5/11 at 11:00 A.M. to have been sitting in a wheelchair in the activity area of the facility. Resident #1's clinical record was reviewed on 12/7/11 at 11:00 A.M. [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) assessment, dated 9/29/11 indicated the resident required extensive assistance of two staff members with bed mobility, transfers and ambulation, and had 1 fall with no injury since the past assessment. The residents admission assessment, dated 4/21/11, indicated the resident required extensive assistance of one staff with transfers, bed mobility and ambulation at that time with a fall prior to admission. The care plan, included a problem, dated 4/19/11 and updated through 12/28/11, for "risk for falls characterized by history of falls/injury, multiple risk factors related to impaired balance, poor coordination, unsteady gait, impaired cognition, which included interventions of "assist resident with transfers with assist of 1 and gait belt initiated 4/19/11, revision 8/24/11, call light in reach, scoop mattress on low bed next to wall, gripper socks/non-slip footwear-4/27/11, resident to be close to staff when up 5/2/11, scoop mattress against wall with bed alarm 6/23/11, revised 8/24/11, when resident is awake, sit with staff close to nurses station, 7/5/11. The fall risk assessments indicated the following concerning falls and interventions added: 4/26/11 resident fell in hallway, high risk of falls, sensor alarm placed in room 5/2/11 resident sitting on floor in front of wheelchair 4/29/11 res to be with staff when up in wheelchair, score 22, above 10 high risk of falls. 7/5/11 resident fell in MDR (Main Dining room) on 7/2/11, neuro checks, chair alarm times 72 hours, sit with staff close to nurses station x-ray right wrist. Nurses notes indicated: 4/25/11 11:30 P.M. resident (sleeping pill) given restoril 15 mg orally for sleeplessness...given at 9 p.m." The 2010 Nursing Spectrum Drug Book, indicated side effects for restoril, included but were not limited to, "depresses the central nervous system, use cautiously in elderly patients,adverse effects include dizziness, light headedness,in-coordination, confusion, irritability, hangover." "4/26/11 3:40 A at 2:45 A.M. a resident walked to me as I was checking another resident and stated that a lady had fell . I walked to the end of the front hall with him and found resident in question on the floor of the doorway across the hall from her room..found no injuries other than numerous bruises..complained of light pain right arm intermittently but mostly pain in left hip. Resident assisted back to bed with assist times 2...order for motion alarm on." "4/29/11 7:50 p.m. Resident attempted to exited wheelchair without assistance and fell . Another resident family hard noise and saw resident on floor between wheelchair and door of front hall...Resident new bruise on left elbow .7 cm by .4 with small abraised area oozing blood, small bruise on left ribs...possible bruise under left eye..." "7/2/11 2045 (8:45 p.m.) Nurses reported to this writer that res fell out of chair at 1800 (6 p.m.) Res reported that she was up in wheelchair in main dining room and leaned over to pick up puzzle piece from floor and fell forward. Res had skin tear right wrist and swelling was noted....chair alarm while up items 72 hours for fall prevention...staff is to sit with resident while at table at all times as a nursing measure..." During interview with the Director of Nursing on 12/7/11 at 12:30 p.m. the resident was sitting in the dining room and the nurse who observed the fall was behind the desk. The resident continued to complain of pain following this fall with an x-ray on 7/5/11 revealing a "pubic ramus fracture." (pelvis fracture). "8/22/11 1230 a.m. This nurse called to shower room, upon entry res noted to be sitting on her bottom in front of the toilet...assisted resident to sit on toilet. floor noted to be wet, dried floor and used gait belt for transfers...." During interview with the Unit Manager who had written this nurses note on 12/7/11 at 12:00 p.m. she indicated a Certified Nursing Aide had taken the resident to the bathroom, who was fairly new and had not used a gait belt during the transfer. She indicated the CNA was counseled and reeducated concerning proper transfers. The Unit Manager indicated gait belts are to be used with any resident who requires actual assistance with transfers. 2. The clinical record for Resident # 41 was reviewed on 12/5/11 at 10:45 A.M. The record indicated Resident # 41 had [DIAGNOSES REDACTED]. The MDS (minimum data set) assessment, dated 11/3/11, indicated Resident # 41 had moderately impaired cognition and required assistance of two with bed mobility, transfers, and ambulation. Resident # 41 had no falls since the last assessment. A Care plan, dated 5/19/11, indicated a problem of "Risk for falls characterized by history of falls/injury, multiple risk factors related to: impaired balance, unstable health condition, use of diuretic, history of falls, requires assist to transfer." The interventions were "Assist resident with transfers with assist of :(blank). Call light within reach and answer promptly. Encourage resident to use handrails or assistive devices properly. Ensure environment is free of clutter. Have commonly used articles within easy reach. Provide toileting opportunities as needed and check for incontinence at least every 2 hours. Reinforce need to call for assistance. Resident to wear proper and non slip footwear. Transfer and Change positions slowly." A Therapy Home Assessment Summary, dated 7/1/11, no time, indicated "...Therapist assisted pt (patient) into house, modification is needed to make is needed to make exit and entry from car to house accessible. Wife is unable to lift w/c into out of trunk of car independently. Wife backed into carport poles entering carport, removing rear view mirror from car...Transfers are unsafe into recliner..." The Nurses Notes, dated 9/12/11 at 5:00 P.M., indicated "Res (resident) on bed at this time. res was previously LOA (leave of absence) with wife. res did not notify staff of his return to facility. res was not back to facility at 4:15 p when checked on res stated arrived to facility at 450 p at this time res stated he did not want to get up and eat dinner because he had fallen at home and his R (right) hip was hurting. no bruises or reddened areas noted at this time. no s/s (signs or symptoms) of dislocation noted at this time..." The Nurses Notes, dated 9/12/11 at 5:30 P.M., (nurse practitioner name) notified of res stating he had fallen at home and that he was complaining of R hip pain. (nurse practitioner name) ordered R hip x-ray at this time DT (due to) R hip pain from recent fall..." The Nurses Notes, dated 9/12/11 at 11:00 P.M., indicated "results of R hip x-ray showed no fracture or dislocation seen. mild osteoarthritis..." The fall care plan was updated on 9/12/11 to include the intervention of "hip xray." During an interview with Unit Manager # 3, on 12/7/11 at 9:30 A.M., she provided a timeline which indicated on 9/12/11 an intervention of "referral to physical therapy." The Physical Therapy Notes, dated 9/8/11, no time, indicated "Unable to evaluate patient for PT (physical therapy) d/t (due to) patient being unavailable (pt (patient) OOF (out of facility) with wife)." The Physical Therapy Notes, dated 9/9/11, no time, indicated "Unable to evaluate patient again for PT d/t pt being OOF with wife." The Physical Therapy Notes, dated 9/12/11, no time, indicated "Patient OOF with wife. Unable to initiate eval (evaluation)." The Physical Therapy Notes, dated 9/13/11, no time, indicated "Unable to eval pt. OOF with wife. I have spoken to wife and informed her of PT eval/tx (evaluation/treatment) order. Pt's wife wanted to take pt out today and wanted him to be eval'd tomorrow. Unit Manager aware of the plan." The Nurses Notes, dated 9/30/11 at 8:30 P.M., "Resident returned to facility. Reported falling at home. Stated "my right leg gave out and I fell on to my R side" Reported calling ambulance for assistance up. No c/o (complaints of) pain at this time. 0.3 cm x (by) 1.5 cm skin tear noted to top of L (left) hand. Area cleansed with water and soap and i (one) steri strip applied." The fall care plan was updated on 9/30/11 to include the intervention of "Chest xray as ordered." The Physical Therapy Notes, dated 10/3/11, no time, indicated "Patient fell at home last weekend. I have spoken to patient regarding safety when going home for a visit. I have expressed to patient that I'm recommending to have somebody/another person aside from his wife when he goes home for safety (his and his wife's safety). Patient agreed. Will speak to patient's wife regarding my recommendations." The Physical Therapy Notes, dated 10/5/11, no time, indicated "I have spoken to patient's wife and patient about last weekend fall incident. I was informed by them that patient was amb (ambulating) with walker towards their vehicle when he turned and fell . Patient's wife claimed that she was beside patient and tried to keep him form falling but was unsuccessful. Patient's wife was educated in home safety measures and was advised to have another capable person to assist her at home when pt (patient) goes LOA with her. Patient and wife understood and agreed on recommendations..." The Nurses Notes, dated 10/11/11 at 3:00 P.M., indicated "Res returned form being LOA with wife and reported he fell at home. Res stated I walked up on the back porch sat down. Mom told me to hold the dog in the wash bucket I got up to walk over to her bent down and hollered Mom I'm going down Mom I'm going down. Res fell backwards on to R hip and buttock. Bumped head on bottom rung of walker. No c/o pain, no bruising or bump on head noted. Res said he is no longer going to get out of the vehicle on his outings with wife. Res had to call ambulance to home to help pick him up. Wife brought him back to facility." The Nurses Notes, dated 10/21/11 at 3:30 P.M., indicated "Res arrived to facility at this time from being LOA (leave of absence) with wife. At this time res stated that he had fallen in Wal-mart while shopping there with his wife. Res complaining of bilateral knee pain and slight pain in back of head...no injuries noted at this time. Res resting on bed at this time." The Nurses Notes, dated 10/24/11 at 10:05 P.M., indicated "Given Lortab (pain medication) at this time. Res stated he was having slight leg and back pain. When res was first asked what had happened, res stated that he hit his leg on the car. He later stated that he had fallen while out with his wife. Bilateral knees slightly reddened res complaining of mild back pain..." The Physical Therapy Notes, dated 10/25/11, no time, indicated "Patient reported that he fell last night at home while attempting to walk to the car. Patient's wife was educated in proper bed to w/c transfers, car transfers, bathroom transfers, wheelchair to chair transfers and in stair climbing. Patient needs CGA (contact guard assistance) with transfers and CGA/minimum assist with ambulation and stair climbing. Constant verbal cues needed for safety. The following recommendation were discussed with patient and wife: 1. When going on LOA, wife is to have another capable person to assist her with transfers, stair climbing and ambulation. 2. Patient is to have gait belt when going on LOA. Nursing staff to apply gait belt before leaving facility. 3. Pt is to use wheelchair at home. Since wife is unable to load/unload wheelchair in car, she is to keep a wheelchair at home. 4. O2 at all times. Pt reported that he takes off O2 and wife carries O2 tank when on LOA. 5. Home assessment- temporarily scheduled for 10/28/11..." In an interview with Physical Therapist # 1, on 12/7/11 at 11:00 A.M., she indicated the resident and his wife refused the home assessment scheduled for 10/28/11. She stated they indicated they had one done previously with the modifications completed. The Nurses Notes, dated 11/14/11 at 10:30 A.M., indicated "Wife signed res out at this time. No c/o per res at this time. Encouraged resident to stay but wife refused..." The Nurses Notes, dated 11/15/11 at 7:30 A.M., "Generalized weakness and lethargy noted...Resident stated fell while LOA with wife and hit back of head. Resident alert oriented to self verbal response inappropriate at times. Speech somewhat slurred...Resident complains of pain on back of head that radiated along R side of head to eye. Confusion noted." The emergency room discharge orders, dated 11/15/11, indicated "...[DIAGNOSES REDACTED]. The fall care plan was updated on 11/15/11 to include the interventions of "E. R. (emergency room ) visit fall outside facility, not to go out with wife, neurochecks." The Nurses Notes, dated 11/15/11 at 4:45 P.M., indicated "Resident's wife in facility. Resident and his wife upset about resident not able to leave facility with wife. Evening shift supervisor and Social Services notified that resident and his wife requesting to speak to them." The Nurses Notes, dated 11/15/11 at 5:15 P.M., indicated "Resident pushed mattress extenders away from low bed and slid off bed onto floor. Assessed for injury then assisted into w/c. No apparent injury noted..." The fall care plan was updated on 11/16/11 to include the intervention of "dysem B/T (between) mattress." The Nurses Notes, dated 11/30/11 at 7:45 P.M., indicated "Res found on floor on his back by CNA at this time. Resident's pants and shoes were off and on floor by res urinal was by resident's side and was smashed. Resident's clothes were wet with urine res fell from wheelchair details of events prior to fall unclear D/T (due to) conflicting statements made by resident as to what happened no injuries noted. res denies pain...immediate interventions were gripper socks and dysem on wheelchair. Neuro checks started at this time..." The fall care plan was updated on 11/30/11 to include the intervention of "gripper socks and dysem to w/c." The Nurses Notes, dated 12/1/11 at 2:45 A.M., indicated "...Client c/o (complaints of) R (right) ankle pain upon assessment of R ankle area noted to have edema with light discoloration around ankle area et (and) pain to touch et pain with slight movement..." A Radiology Report, dated 12/1/11, indicated "...Ankle right....There is fracture involving distal fibula with minimal displacement..." The Nurses Notes, dated 12/2/11 at 9:45 P.M., indicated "Res found sitting on bathroom floor beside wheelchair by CNA. Res was trying to toilet himself and stated that when he grabbed the grab bar his hand slipped and he fell to the floor. Resident stated he did not hit his head and that he landed on his buttocks. No injuries noted. Res denies pain...immediate interventions is NO (new order) for res to be up in common areas when in w/c..." The fall care plan was updated on 12/2/11 to include the intervention of "Res (resident) in common areas when in w/c." 3.1-45(a)(2)

Based on interview, record review and observation, the facility failed to ensure residents who were at high risk of falls were provided supervision and interventions implemented to ensure their safety for 3 of 9 residents reviewed with falls in the sample of 15. Resident E, who had repeated falls and was at a high risk of falls was left in a lift chair, and fell out of the chair resulting in fractures, Resident C was left in his room without supervision on two occasions after the facility developed the intervention to not have him in his room alone resulting in falls, and Resident S had repeated falls without alternate interventions implemented or supervision increased. Findings include: 1. On 12/15/10 at 9:00 A.M., during the tour of the locked dementia care unit, Resident E was observed to be in a low bed with two stacked mattresses on the floor beside the bed. Resident E was observed to have a dressing across the bridge of her nose. Massive bruising was observed around the eyes and the entire nose. Resident E was also observed to have a sling on the right arm. A black electric lift chair was observed in the resident's room. The control to the chair was observed to have been long enough to have placed in the center back of the chair out of the resident's reach. The clinical record for Resident E was reviewed on 12/15/10 at 9:55 A.M. The record indicated Resident E had [DIAGNOSES REDACTED]. The MDS (minimum data set) assessment, dated 11/11/10, indicated Resident E had impaired decision making. Resident E required extensive assistance of two with bed mobility, transfers, ambulation and toilet use, and had fallen. A Care Plan, dated 1/6/10, indicated a problem of "Risk for falls characterized by history of falls/injury, multiple risk factors related to: impaired balance, unsteady gait, history of falls." The interventions were "Assist resident with transfers with assist of two. Call light within reach and answer promptly. Encourage resident to use handrails or assistive devices properly. Ensure seating in dining room is close to entrance/exit. Place resident in fall prevention program. Provide toileting opportunities as needed and check for incontinence at least every 2 hours. Resident to wear proper and non slip footwear. 11/30/09 fall team met and review risk assessment. 12/26/09 see fall risk assessment (fell in room). 2/23/10 fall team met and reviewed fall risk assessment." During interview with the unit manager, on 12/20/10 at 9:05 A.M. she indicated the fall prevention program, consisted of any resident at high risk of falls, and the staff tried to watch them closer and be proactive. A Fall Risk Assessment, dated 7/27/10, indicated a score of 18. The form indicated "Total score above 10 represents HIGH RISK." The Nurse's Notes, dated 9/19/10 at 9:00 P.M., indicated "Alarm sheet continues, Res (resident) exhibits poor safety awareness, has slid down in recliner x (times) 2 alarm sounding, res wanted to get up and find something she 'needed'. Staff assisted res up in recliner to correct sitting position. Call light in reach, res not using. Feet elevated." The Nurse's Notes, dated 9/19/10 at 9:20 P.M., indicated "This nurse walking down hall noted res not sitting in recliner correctly. Res slid down, her head was in the seat and feet where (sic) hanging over foot rest. Res assisted to bed at this time with ii (two) assist." The Nurse's Notes, dated 9/21/10 at 11:30 A.M., indicated "Res sliding down in recliner. Staff asked res if they could help reposition her. Res refused assistance from staff wanting to do it herself. Res did get slightly better positioning. Chair alarm functioning properly." The Nurse's Notes, dated 9/29/10 at 5:20 A.M., indicated "This nurse heard alarm sounding upon entering room, noted res lying on floor on R (right) sight (sic) between matts and the bed. This nurse yelled for other 3 CNAs, res examined no redness noted, no injury noted denies pain/discomfort. Res stated I was going to walk over to my recliner and sit down. Res did not use call light and was incont (incontinent) of urine. When asked what happened res stated 'well honey I used my pads and I sat down in the floor and I couldn't get back up,' denies hitting head, assisted back to bed with 4 assist..." The Nurse's Notes, dated 9/29/10 at 9:00 A.M., indicated "(Name) DoN (Director of Nursing) aware of fall interventions to include voiding diary for 3 days, bladder scan, PT (physical therapy) screen after ATB (antibiotic) finished et (and) slipper socks at hs (bedtime)..." A Nursing to Therapy Referral Form, dated 9/29/10, indicated "...Nursing Request-Falls or slips forward/side, Frequent falls...Do screen after 10/6/10 R/T (related to) currently on ATB (antibiotic)." The Fall Risk Assessment, dated 9/29/10, indicated "...Ongoing/Periodic Evaluations- Res fall this AM. Kicked matt (sic) extenders away from bed et was in between bed et matt (mattress) extenders. Told staff she was walking to recliner. Bladder scan, voiding diary x (times) 3 days, PT screen after ATB, slipper socks at hs." The fall care plan was updated 9/29/10, to include the intervention of "See fall risk assessment (res fall in room in between bed and mattress)." The Nurse's Notes, dated 10/11/10 at 11:05 P.M., indicated "...confused to time and place...Res has poor safety awareness attempts to get up out of bed and recliner, sounding alarms...." The Nurse's Notes, dated 10/19/10 at 1:30 A.M., indicated "Resident attempting to climb out of bed...pressure alarm in place...." The Nurse's Notes, dated 10/21/10 at 3:40 P.M., indicated "DC (discontinue) bed/chair alarm...Daughter (name) aware states 'cool she'll like that' IDT (interdisciplinary team) met this date D/T (due to) no falls in last 3 weeks et (and) interventions of matt extenders, low bed et Dysum (sic) (non-slip material). Alarms to be DC'd. Will continue to monitor." The Nurse's Notes, dated 10/23/10 at 8:20 P.M., indicated "Res with call light on, this nurse was in room within 3 min (minutes), res was attempting to get up out of recliner, res was sitting on the edge. res wanting to use BSC (bedside commode) explained I would get some one to help me and I would be right back. Res stated 'Oh s--- I can go (sic) it myself.' Res displays very poor safety awareness and gait is unsteady. This nurse stayed with res until CNAs got to room and res was assisted...." The Nurse's Notes, dated 10/25/10 at 2:50 A.M., indicated "...Poor safety awareness...." The Nurse's Notes, dated 11/11/10 at 5:35 P.M., indicated "CNA yelled for help. I responded found resident lying on back in floor by BSC (bedside commode)...Resident checked for injury with none found and resident denied pain or injury. Assisted up per 2 staff. Placed in w/c and taken to living room to eat supper...Resident had call light on chair and with in reach, but did not use. Dysum was in recliner. Resident said she was trying to get to BSC. Resident was toileted before supper at 4:00 P.M. Neuro checks started since unwitnessed." A Fall Risk Assessment, dated 11/11/10, indicated a score of 18. The form indicated "Total Score above 10 represents HIGH RISK." The Fall Risk Assessment, dated 11/15/10, indicated an intervention of "Res up w/c (sic) et in DR (dining room) to eat." The fall care plan, dated 1/6/10, was updated on 11/15/10 to include the intervention of "See fall risk assessment (fall in room)." The Nurse's Notes, dated 11/24/10 at 3:30 P.M., indicated "Attempt to ambulate to w/c to read what the label said- legs gave out and sat down on floor...Active ROM (range of motion) of all extremities within usual range..." A Fall Risk Assessment, dated 11/24/10, indicated a score of 20. The form indicated "Total Score above 10 represents HIGH RISK...Ongoing/Periodic Evaluations- Dysum changed in recliner..." The Nurse's Notes, dated 11/24/10 at 5:00 P.M., indicated "Found resident sitting on commode- ambulated self by holding onto overbed table again instructed to use call light. Stated 'I'm not going to.'" The Nurse's Notes, dated 11/28/10 at 3:30 P.M., indicated "Found resident sitting on floor with lift chair with foot rest up. Resident stated 'I went to the bathroom and my pants are not back on right.' BSC approx (approximately) 5 ft. from lift chair. Denied pain. Stated 'of course I'm not hurt.'..." A Fall Risk Assessment, dated 11/28/10, indicated a score of 20. The form indicated "Total Score above 10 represents HIGH RISK." The Nurse's Notes, dated 11/29/10 at 3:10 P.M., indicated "PT/OT (physical therapy/occupational therapy) eval (evaluation) et (and) tx (treatment) R/T (related to) fall..." The fall care plan, dated 1/6/10, was updated on 11/29/10 to include the intervention of "11/24/10 see fall risk assessment (fall in room) and 11/28/10 see fall risk assessment (fall in room)." A Seating and Positioning Evaluation, dated 11/30/10, indicated "...Reason for Referral: Increase falls from recliner...Cognition: Alert and oriented to self. Poor safety awareness. Attempts activities I (independently) when should ask for A (assist)...Additional Comments: OT to maximize/assess safety in current recliner et educate staff." An instruction sheet, Positioning in Recliner for (Resident E), no date, indicated "First and foremost (Resident E) should be positioned all the way back in her recliner each time she is transferred into it. To assist you in doing this, put a draw sheet down in her recliner with dicem (sic) on top and once she is in the chair, grab each side of the draw sheet and pull her all the way back in the chair. Second, check on (Resident E) frequently. When you pass by her room, take a peek and make sure she is still all the way back in her chair. If not, get a second person and pull her back again. Third, when serving (Resident E) her tray, make sure she is positioned back in the chair and lower the legs. Only lower the legs to neutral. Do Not put the recliner in a slightly elevated position. This encourages the forward motion and can assist her in sliding out of her recliner. Lastly, (Resident E) tends to lean to the left, therefore you can position a pillow along her left side, however, a pillow behind her back only pushes her forward, so only a pillow to her side." A Therapy-Nursing Communication, dated 12/3/10, indicated "...After transferring (Resident E) into her lift chair or when checking on her in her room please make sure SHE IS ALL THE WAY BACK IN HER CHAIR. HER BOTTOM SHOULD BE PULLED ALL THE WAY BACK..." The Nurse's Notes, dated 12/3/10 at 8:50 P.M., indicated "I was called to resident's room by staff nurse. Resident was lying on back in floor. Resident said she dropped her glasses and slipped out of chair trying to pick them up. Call light was attached to recliner but resident did not use. Dysum was also in chair. Gripper socks on...Resident was able to move all extremities well. Denies any injury..." The Nurse's Notes, dated 12/3/10 at 9:15 P.M., indicated "(Daughter's name) returns my call and told of fall. Requested bed alarm be used. She will speak with UM (unit manager) regarding use." The Nurse's Notes, dated 12/3/10 at 9:30 P.M., indicated "Order received from (name) NP (nurse practitioner) to do PT (physical therapy) eval and treat." A Fall Risk Assessment, dated 12/3/10, indicated a score of 20. The form indicated "Total Score above 10 represents HIGH RISK." The fall care plan, dated 1/6/10, was updated on 12/6/10 to include the intervention of "12/3/10 see fall risk assessment (slipped out of chair)." The Nurse's Notes, dated 12/6/10 at 2:00 P.M., indicated "Res (resident) currently on therapy caseload. Wedge cushion add (sic) to recliner to help res from sliding out of recliner." The Fall Risk Assessment, dated 12/6/10, indicated "...Ongoing/Periodic Evaluations- wedge cushion to recliner. 12-6-10 wedge cushion too big for recliner. PT ordering new wedge. Staff continue with draw sheet to reposition re in chair per tx (treatment) assess." The Nurse's Notes, dated 12/8/10 at 8:45 P.M., indicated "Pt (patient) calling from room. CNA enters and finds pt on floor, face down. QMA (qualified medication aide) (name) summons this nurse to room. Noted pt to be face down on floor in front of recliner L (left) arm extended out from body and R (right) arm positioned in abnormal way at side. Pt's head turned on R cheek noted 1 inch laceration above L brow and 7 mm (millimeter) split in skin on bridge of nose. Pt able to move both feet without c/o (complaint of) pain. Yells out when R arm lightly touched...New order to send to (hospital name) ER (emergency room ) for eval and tx...pt noted to have proper footwear (socks and shoes) when found." The emergency room Physician Orders, dated 12/9/10 at 12:25 A.M., indicated "...Follow up with ENT (ears, nose, throat physician) next 24-48 hours (consult) Fx (fractured) nose. Fx R humerus (proximal)." In an interview with the Occupational Therapist, on 12/20/10 at 9:20 A.M., she indicated she felt Resident E's recliner was 'way too big'. She indicated the family wanted Resident E to keep the recliner. She indicated Resident E 'played' with the remote to the lift chair and it allowed place the chair in an upright position and slide out. She further indicated she thought placing the remote to the chair out of the residents reach could be considered a restraint so had not done so. In an interview with the Unit Manager for Resident E's unit, on 12/20/10 at 9:25 A.M., she indicated the staff attempted to keep the remote for the chair in the side pocket of the chair. She indicated the staff had not thought of putting the remote behind the chair. The care plan, dated 1/6/10, did not address the electric controls for the resident's lift chair. The facility was asked for the policy and procedure for the fall prevention program on 12/20/10 at 11:00 A.M. The DON and administrator, indicated at 11:40 A.M. this same day that there was no specific policy for fall prevention program. 2. During the initial tour of the locked dementia care unit, on 12/15/10 at 9:00 A.M. Resident C was observed in the main dining area. The clinical record for Resident C was reviewed on 12/15/10 at 11:40 A.M. The record indicated Resident C had [DIAGNOSES REDACTED]. The MDS (minimum data set) assessment, dated 11/11/10, indicated Resident C had impaired memory and decision making ability. Resident C required extensive assistance of two with bed mobility and toilet use. Resident C required extensive assistance of one with transfers and ambulation. Resident C had fallen since the last assessment. The Fall Risk Assessment Fall, dated 7/30/10, indicated a score of 17. The form indicated "Total Score above 10 represents HIGH RISK...Prevention Intervention indicated "scoop mattress, low bed, gripper socks and bed next to wall." The Nurse's Notes, dated 9/2/10 at 7:15 A.M., indicated "This nurse had just counted out med cart and started med pass, when resident from room (number) came quickly down the hallway in w/c and stated 'a lady fell ', this nurse and nurse (name) and CNAs on floor immediately ran up the hall and found resident from room (Resident C) on floor in room lying with stomach and face down (mainly on L (left) side) on the floor in the room between resident's bed and bathroom door, resident unresponsive, nurse (name) took vitals and assessed resident while this nurse immediately call (name) hospital ambulance resident was wearing regular socks and low bed was in low position but not all the way down call light was in reach on side of bed, call light not used at the time by resident..." A Fall Risk Assessment, dated 9/2/10, indicated a score of 17. The form indicated "Total score above 10 represents HIGH RISK...Ongoing/Periodic Evaluations: res (resident) fell in room, apparent injury, sent to ER (emergency room ) no call light used." The Nurse's Notes, dated 9/4/10 at 4:30 P.M., indicated "Resident returned per ambulance...Resident alert with confusion noted-L (left) eye has red bruising noted-Dx (diagnosis) subdural hematoma..." The Fall Risk Assessment, Fall Prevention Intervention was updated on 9/4/10 to include "Mat on floor." The Fall Risk Assessment, Fall Prevention Intervention was updated on 9/10/10 to include "Bed alarm." The Nurse's Notes, dated 10/15/10 at 1930 (7:30 P.M.), indicated "Res found in room on floor (lying). Res attempted to get out of wc. CNA who found res yelled for this nurse. This nurse took res VS (vital signs) et helped get him in wc. Res showed no signs of injuries...Will do fall charting for 48 hours." The Fall Risk Assessment, Fall Prevention Intervention was updated on 10/15/10 to include "staff education." A Fall Risk Assessment Ongoing/Periodic Evaluations, dated 10/18/10, indicated "Res fall in room; staff educated fall risk et (and) need to be in MDR (main dining room) monitored by AA's (activity assistants) needs assistance for transfers." A memo, dated 10/18/10, indicated "All staff read, sign and date: (Resident C) is a fall risk. He should be in the MDR (main dining room) with the activity assistants. When he is in his room he should be in bed with his bed in low position, alarm turned on, and mattress extenders bedside the bed. If he is in his room in his wheelchair then staff should be with him. He is to only wear gripper socks, this includes when he has shoes on (Gripper socks ONLY) When drinking coffee or anything hot he is to use a cup with a lid. Do not let him have a regular coffee cup. If you have questions please ask." A Fall Risk Assessment, dated 12/9/10, indicated a score of 16. The form indicated "Total Score above 10 represents HIGH RISK." The Nurse's Notes, dated 12/12/10 at 11:00 A.M., indicated "Found resident sitting on floor in front of closet with w/c beside him in unlocked position. Resident stated 'I was trying to get these clothes out of here, they're not mine." Assess for injury. Active ROM (range of motion) within usual range...tearful because he fell . Skin tear top of L (left) hand 10 cm L (length) x (by) 2 cn W (wide). Skin tear R (right) medial wrist 4.0 cm L x < (less than) 1.0 cm W...returned to supervised dining area." The Fall Risk Assessment Ongoing/Periodic Evaluations, dated 12/13/10, indicated "Staff education." A memo, dated 12/13/10, indicated "All Activity Assistants Read and Sign: There is a list on Unit 1 in the activity folder that has a list of fall risk resident's (sic). Those residents are to be monitored at all times. If you have multiple groups going on at once it is expected that there will be an activity assistant in each area. There needs to be constant moving to monitor the residents." In an interview with the Director of Nursing and the Assistant Director of Nursing, on 12/15/10 at 1:00 P.M., they indicated that Resident C was not to have been in his room without supervision. 3. During the initial tour of the locked dementia unit, on 12/15/10 at 9:00 A.M. Resident S was observed in the main dining room. The clinical record for Resident S was reviewed on 12/15/10 at 11:05 A.M. The record indicated Resident S had [DIAGNOSES REDACTED]. The MDS (minimum data set) assessment, dated 11/18/10, indicated Resident S had impaired memory and decision making ability. Resident S required limited assist of one with bed mobility and ambulation. Resident S required extensive assistance of two with transfers and extensive assistance of one with toilet use. Resident S had fallen since the last assessment with two or more of the falls resulting in no injury and two or more of the falls resulting in injury. The Fall Risk Assessment, dated 8/24/10, indicated "...fall 6/4/10, 6/6/10, 7/9/10, 7/18/10, 8/17/10..." and a score of 15. The form indicated "Total Score above 10 represents HIGH RISK." The Nurse's Notes, dated 9/3/10 at 10:10 A.M., indicated "Heard res (resident) yelling out 'help me help me' This QMA (qualified medication aide) went into room and found res lying on her R (right) side between the bed and mattress extenders...Res had kicked mattress extenders away from the bed and had turned off her alarm..." The Nurse's Notes, dated 9/3/10 at 3:00 P.M., indicated "Dysum added to in between mattress extenders et (and) on floor..." The Fall Risk Assessment, dated 9/3/10, indicated a score of 15. The form indicated "Total Score above 10 represents HIGH RISK...Fall Prevention Intervention, dated 9/3/10, indicated "Dysum in between matt (mattress) extenders et on floor...Ongoing/Periodic Evaluations: Res turned off alarm et kicked mattress extenders away from bed. Found on side in between bed et matt extenders. Dysum on floor et in between matt extenders." A fall intervention, dated 7/9/10, indicated "Keep alarm out of reach." The Nurse's Notes, dated 9/14/10 at 1:30 A.M., indicated "This nurse heard resident yell 'help me'. Found resident lying on floor on her back. Resident said she got out of bed on mattress extenders and slid over to floor. ROM (range of motion) good...No apparent injury seen...Bed alarm was on and functional but would not alarm because incont (incontinent) pad on bed. Pad removed and alarm working..." The Nurse's Notes, dated 9/14/10 at 12:50 P.M., indicated "Spoke with daughter (name) regarding res (resident) changing planes early this AM. Advised PT (physical therapy) would be evaluation res for balance testing. Daughter pleased PT would be evaluating res for balance testing..." The Fall Risk Assessment, dated 9/14/10, indicated a score of 19. The form indicated "Total Score above 10 represents HIGH RISK...Fall Prevention Intervention, dated 9/14/10, indicated "PT (physical therapy) or OT (occupational therapy) screen...Ongoing/Periodic Evaluations: Res fall in room: Res scooted from bed to matt extenders then to floor. PT to eval (evaluate) et tx (treat)." The Nurse's Notes, dated 10/7/10 at 5:30 A.M., indicated "This nurse was assisting with bed check in another resident room when I heard someone hollering. NA (nursing assistant) went to check found (Resident S) in floor of her bathroom saying I need to have a BM (bowel movement). Bed alarm was turned on but did not sound resident was wearing regular socks...Resident denies pain or discomfort...Slipper socks put on and new bed alarm placed in bed." The Fall Risk Assessment, dated 10/7/10, indicated a score of 19. The form indicated "Total Score above 10 represents HIGH RISK...Fall Prevention Intervention, dated 10/7/10, indicated "replace faulty alarm and all nylon socks removed et replaced with gripper socks... A fall intervention, dated 6/4/10, indicated "Nonskid socks." The Nurse's Notes, dated 10/10/10 at 1635 (4:35 P.M.), indicated "Res sitting in MDR (main dining room) at 4:30 pm at the table. AA (activity assistant) was sitting with res et got up to assist another res when this res attempted to get up out of chair et fell to the floor et hit head on leg of table. This nurse immediately told staff to get weekend supervisor et began checking...Gave res PRN (as needed) Tylenol for H/A (head ache) et attempted to apply ice to her head which res refused..." The Nurse's Notes, dated 10/10/10 at 11:30 P.M., indicated "...Res had a "bump" on back of her head from fall..." The Fall Risk Assessment, dated 10/10/10, indicated a score of 19. The form indicated "Total Score above 10 represents HIGH RISK...Fall Prevention Intervention, dated 10/9/10, indicated "Keep in view when in MDR (main dining room)...Ongoing/Periodic Evaluations: 10/11/10- Res fall in MDR on 10-10-10. Sitting at table et fell . Res to be kept in view of staff when out in MDR." The Nurse's Notes, dated 10/13/10 at 6:00 A.M., indicated "pt (patient) was put to bed by QMA (qualified medication aide) (name) alrmed (sic) turned on 5 mins later pt walking out of room in hall way stating I'm ready to go home and alarmed (sic) checked and it was off pt takin (sic) to dining room for coffee." The Nurse's Notes, dated 10/13/10 at 8:40 A.M., indicated "Motion sensor alarm arrived et put in room on dresser. Bed alarm removed." The Nurse's Notes, dated 10/21/10 at 3:30 P.M., indicated "IDT (interdisciplinary team) met to discuss res et falls. Motion sensor alarm DC'd (discontinued) D/T (due to) increased agitation with alarm sounding. Dysum, low bed et matt extenders remain in place for safety...." The Nurse's Notes, dated 10/23/10 at 1740 (5:40 P.M.), indicated "Res yelled out et was heard by this nurse at nurses desk. When entering res's room noted that res was sitting on floor. When asked what happened res stated she was going to bathroom et fell . This writer asked which way she fell et if she hit/hurt anything. Res stated that she sat on the floor on her bottom...." The Fall Risk Assessment, dated 10/23/10, indicated a score of 19. The form indicated "Total Score above 10 represents HIGH RISK...Ongoing/Periodic Evaluations: Res climbed out of bed. Staff to chart outside res room to witness res climbing out of bed. 10/25/10-CNA witness res kicking matt extenders et scooting out on bottom matt extender." The Nurse's Notes, dated 10/23/10 at 1820 (6:20 P.M.), indicated "Res climbed out of bed et walked to nurse's desk to tell us that she wanted to go home." The Nurse's Notes, dated 10/24/10 at 12:50 P.M., indicated "Res was walking from her bedroom toward MDR without assistance et sat on floor. She said her legs were weak. This nurse asked her to please use her call light so that we can help her up. Res had no complaints or injuries." The fall prevention interventions were not updated after resident sat in floor. The Nurse's Notes, dated 10/24/10 at 5:00 P.M., indicated "Res has repeatedly gotten out of bed with no assistance and without using call light despite re-education from staff..." The Nurse's Notes, dated 10/28/10 at 1:05 A.M., indicated "...Very poor safety awareness. Must be monitored d/t (due to) trying to get up by herself." The Nurse's Notes, dated 11/2/10 at 5:30 A.M., indicated "Res found sitting in floor on bottom stated 'I slid off of mattresses, landed on bottom.' Denies hitting head assess for injuries with none noted. Res assisted up toileted et layed (sic) back in bed with mattress extender in place. Instructed to use call light." The Fall Risk Assessment, dated 11/2/10, indicated a score of 19. The form indicated "Total Score above 10 represents HIGH RISK...Ongoing/Periodic Evaluations: Res climbed out of bed et off of mattress extenders onto floor. No injuries noted." In an interview with the Assistant Director of Nursing, on 12/20/10 at 9:50 A.M., she indicated the intervention after the fall on 11/2/10 was "Resident toileted, Ativan (antianxiety medication) changed from 1 mg every 12 hours to 1 mg tid (three times daily)." The Nurse's Notes, dated 11/18/10 at 6:20 P.M., indicated "Nurse's at desk doing report heard a noise CNA yelled for a nurse. Upon entering room noted res sitting on bottom,, c/o (complaints of) hitting arm/elbow on dresser denies hitting head. Res examined moves arm without pain or difficulty. Res examined skin tear noted 1.0 x (by) 0.4 x < (less than) 1 cm...Res stated she was going back to bed. She had to go to BR (bathroom) she didn't know what happened she just fell ..." The Fall Risk Assessment, dated 11/18/10, indicated a score of 20. The form indicated "Total Score above 10 represents HIGH RISK...Fall Prevention Intervention, dated 11/19/10, indicated "Bladder scan...Ongoing/Periodic Evaluations: Bladder scan R/T (related to) fall." The Nurse's Notes, dated 11/20/10 at 11:00 P.M., indicated "This nurse was at nurse's desk heard 'help' found resident sitting on floor next to bolsters resident stated 'I went to the bathroom and fell here.' Resident states 'I sat down'...No injury..." The Fall Risk Assessment, dated 11/20/10, indicated a score of 19. The form indicated "Total Score above 10 represents HIGH RISK...Fall Prevention Intervention, dated 11/20/10, indicated "Resident education on call light use..." The Nurse's Notes, dated 11/22/10 at 10:00 A.M., indicated "IDT (interdisciplinary team) met et discussed res fall on 11/20/10. Night light to be added to res room as interventions will continue to monitor." The Nurse's Notes, dated 11/25/10 at 7:30 P.M., indicated "Res found in room on floor in front of mattress extenders. Res reported transferring self to bathroom and fell while trying to get back to bed. Res reported that she tripped over extenders. Resident was educated on call light se and was offered BR Q (every 2 hours no s/s (signs or symptoms) of injury were noted." The Fall Risk Assessment, dated 11/25/10, indicated a score of 19. The form indicated "Total Score above 10 represents HIGH RISK.." The form lacked any fall prevention interventions were put in place after the 11/25/10 fall. In an interview with the Assistant Director of Nursing, on 12/20/10 at 9:50 A.M., indicated the intervention put in place was "Resident toileted." The Nurse's Notes, dated 12/4/10 at 9:00 P.M., indicated "Res was found by CNA sitting on the floor in her room at the end of the mattress extenders. Res was yelling for help et reported that she went to BR and fell on the way back to bed...nonskid socks on. Toileting program in place, offer BR upon arising before and after meals, at bedtime et as needed. Call light in reach." The Fall Risk Assessment, dated 12/4/10, indicated a score of 21. The form indicated "Total Score above 10 represents HIGH RISK...Fall Prevention Intervention, dated 12/4/10, indicated "Activity box for evening..." In an interview with the Assistant Director of Nursing, on 12/20/10 at 9:50 A.M., she indicated the intervention put in place, was "Resident moved to supervised area." The Nurse's Notes, dated 12/5/10 at 5:00 A.M., indicated "...Res was found by CNA sitting on the floor in her room at the end of the mattress extenders. Res was reporting that she went to the BR and fell on the way back to be (sic). No s/s of injury noted." The Nurse's Notes, dated 12/5/10 at 10:20 (no A.M. or P.M.), indicated "Res was found sitting on floor in room 119...No injuries noted...This occurred at 8 a.m. Res denies any pain et stated she was 'fine' will continue to monitor." The Fall Risk Assessment, dated 12/5/10, indicated a score of 21. The form indicated "Total Score above 10 represents HIGH RISK...Ongoing/Periodic Evaluations: 12/6/10 IDT met et use activity box to occupy res. Continue to monitor res for continuely (sic) scooting off matt extender (ref (reference) 12/4, 12/5)." The Nurse's Notes, dated 12/6/10 at 2:00 P.M., indicated "IDT met et reviewed res falls from weekend. Activity basket made to occupy res time in evening. Will continue to monitor res for kicking matt extenders over et scoot (sic) onto floor." In an interview with the Unit Manager for Resident S's unit, on 12/20/10 at 10:30 A.M., she indicated the interventions for the 12/4/10 and each of the two falls on 12/5/10 were the same of activity box. The Nurse's Notes, dated 12/10/10 at 1:00 A.M., indicated "QMA was walking hallway and found resident sitting in floor next to mattress extenders. "I'm all right."...No noted injuries...Resident said she was going to bathroom. Assisted up per 2 staff and taken to BR." The Fall Risk Assessment, dated 12/10/10, indicated a score of 20. The form indicated "Total Score above 10 represents HIGH RISK...Fall Prevention Intervention, dated 12/10/10, indicated "15 minute checks...Ongoing/Periodic Evaluations: 15 min checks." The Nurse's Notes, dated 12/13/10 at 4:10 P.M., indicated "...Res found sitting next to matt extenders. No injury noted. Res stated 'I scooted off those things' Res had been toileted 10 min prior. Res toileted again et put back to bed per her request." The Nurse's Notes, dated 12/13/10 at 4:25 P.M., indicated "...At this time staff walked by res room et res sitting on mattress. Res brought to MDR. Will continue 15 min checks et monitor for res crawling/scooting off matt extender." The Fall Risk Assessment, dated 12/13/10, indicated a score of 19. The form indicated